Every finding on record at Hallmark Hospice Care LLC

Based on record review and interview, the Hospice’s written emergency preparedness and response plan (ERP) failed to include a continuity of operations plan that addressed patient populations, but not limited to patients a-risk; types of services the agency has the ability to provide in an emergency; delegation of authority and how to return to normal operations as quickly as possible for 1 of 1 plan reviewed. This failure could place the Hospice’s clients at risk of harm when the Hospice does not have a plan to include and restore essential functions during a natural or man-made disaster or emergency. --- The findings included: Record review of the Hospice emergency preparedness and response binder included an “Emergency Preparedness Plan and Procedure”, not signed and reviewed 01/31/24, that documented “Recovery…Activities implemented during and after a disaster that are designed to return the Hospice to its normal operations as quickly as possible….Emergency Preparedness Plan and Procedure Checklist…Develop the Emergency Preparedness Plan…include mitigation, disaster response and recovery activities for clinical and administrative operations…Complete the Continuity Business Plan to ensure Quick recovery of the Business. Further Record review the Hospice ERP binder included a “Continuity of Operations Business Plan” that documented “Continuity of Operations Business Plan for… [Agency B] … address… [address to Agency B] … completed by RN A and signed and dated on 01/31/24. Record review of the Continuity of Operations Business Plan failed to address emergency financial needs, essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible for the Hospice. In a simultaneous record review of the Hospice’s ERP binder and “Emergency Preparedness Plan and Procedure” on 04/15/25 at 03:00 p.m., the Adm stated she had not really been involved in the Hospice’s Emergency Preparedness since being appointed Adm in December 2023. The Adm stated the Hospice had no active clients at the moment. The Adm stated the Hospice put all the employees on standby temporarily. The Adm stated she was not sure who the Disaster Coordinator was, but after reviewing the Continuity of Operations Business Plan she stated RN A was. The Adm stated the Alt Disaster Coordinator was not active or employed. The Adm stated the Continuity of Operations Business Plan was not accurate or updated. The Adm stated the Continuity of Operations Business Plan was for Agency B. The Adm stated RN A was employed by Agency B and may have used their Continuity of Operations Business Plan when she was “helping me with all of this”. The Adm stated RN A did not update the Continuity of Operations Business Plan to reflect the Hospice’s information on the plan. The Adm stated RN A was not available for interview. The Adm stated she, herself, had not reviewed the emergency preparedness binder “until just now”. The Adm stated “it is really incorrect and not our [the Hospice’s] plan. The Adm stated the DON was not involved in the development of the Continuity of Operations Business Plan. The Adm stated she hired RN A to “be in charge of it”. The Adm stated the DON was “supposed to be “overseeing” RN A but “she was not”. The Adm stated the Agency did not have a Continuity of Operations Business Plan. The Adm stated it was her responsibility to ensure the Hospice had a complete and accurate Emergency Preparedness Plan and Continuity of Operations Business Plan. The Adm stated she had no answer as to why this was not looked at. The Adm stated “a lot was going on…too much to put in place…no excuses…me not taking care of it…” The Adm stated the Hospice was not following its policy for emergency preparedness. Record review of the Hospice’s policies titled, “Emergency Preparedness and Response Plan EC.40”, with a revised date, 01/31/24, quoted in part, “The Hospice will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services. The plan will…C. Provide for continuity of patient care and business operations including delegations of authority and succession plans…VI Continuity of Business Operations Plan…”

Based on record review and interview, the Hospice failed to maintain, implement, and review a Quality Assessment Performance Improvement (QAPI) program for 1 (2024) of 3 years reviewed in that: The Hospice did not maintain a QAPI program implemented by its QAPI committee that reviewed, updated, or revised the plan of implementation at least once within a calendar year, or more if needed for 2024. The QAPI Committee did not meet twice a year or more often if needed for 2024. --- This failure placed the Hospice’s patients at risk of receiving inadequate care and services due to the Hospice not being able to track and trend patterns in negative patient care outcomes and prevented the Hospice from identifying any potential issues that needed to be addressed or worked on at the Hospice. Record review of the Hospice’s QAPI binder included a “Quality Assurance Performance Improvement Plan (2023) and (2022)”. Record review of the Hospice’s QAPI binder included “Quality Assessment and Performance Improvement (QAPI) Quarterly” reports and “Quality Assessment Improvement (QAPI) Committee Meeting Minutes” for 2023 and 2022 dated as follows: ·       04/11/22, 07/21/22, 01/02/23, 04/14/23, 07/14/23, and 10/09/23. Record review of the Hospice’s QAPI binder failed to include documentation that the QAPI program was implemented, reviewed, updated, or revised by the QAPI committee during 2024. In an interview on 04/14/25 at 02:10 p.m., the Adm stated, “Nothing has been done for QAPI for year 2024”. In a subsequent interview and simultaneous record review on 04/14/25 at 03:45 p.m., the Adm stated she did not know the answer to who the QAPI committee was. The Adm stated she did not know when the last time QAPI committee had a meeting. The Adm stated she was not sure who was part of the QAPI committee but thought it might include a RN, LVN, MSW, CH, and herself, the Adm. The Adm stated she was not sure how many times QAPI was supposed to meet but believed it was 2 times per year per the Hospice’s policy. The Adm stated the Hospice did not meet in 2024. The Adm stated she did not know she was responsible for the oversight of the QAPI or what the purpose of it was. The Adm stated she had a RN A helping her run the Hospice, but all the staff were currently on standby because there were no active patients. The Adm stated “we did not get that far [catch up with all required tasks including QAPI]”. The Adm stated the hospice has not had any meetings since 2023 and that could have a “pretty” negative impact to the Hospice and patients. The Adm stated, “that is why the Hospice is in the situation we are in right now”. The Adm stated the Hospice was not following its policy regarding QAPI and that it was her responsibility for the oversight of it.In an interview on 04/15/25 at 10:45 a.m., the DON stated the role of the DON in QAPI was to “help improve the quality care for the clients and to lead”. The DON stated the Agency had not maintained QAPI program in the past year but had “improved in quality”. The DON stated the Agency had not focused on QAPI because they had been “working to explain everything [transition in electronic medical record system] to the staff”.Record review of the Hospice policies titled, “Quality Assessment Performance Improvement Program QAPI.5”, with a revised date 10/01/21, quoted in part, “The Hospice will define, implement and maintain an effective, ongoing, hospice-wide data driven QAPI plan that is evaluated, reviewed, and updated or revised annually or more often if needed, by the QAPI Committee…” Record review of the Hospice policies titled, “Quality Assessment Performance Improvement Program QAPI.5”, with a revised date 10/01/21, quoted in part, “Execute responsibilities. The Hospice’s Governing Body is responsible for ensuring the following…That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually…”Record review of the Hospice policies titled, “Quality Assessment Performance Improvement Program QAPI.5-TX”, with a revised date 04/14/23, quoted in part, “In Addition to the requirements defined in the Quality Assessment Performance Improvement Program policy in the Quality Assessment Performance Improvement (QAPI) Program section of the Administrative Policy Manual, the following requirements will be met…The QAPI Committee will meet twice a year or more often if needed and will maintain a written record of the meetings with appropriate signatures…”

Based on record review and interview, the Hospice failed to enforce written policies to provide annual Infection Control and Bloodborne Pathogen education as required by the Occupational Safety and Health Organization (OSHA), 29 Code of Federal Regulations (CFR) part 1910.1030 and Appendix A relating to Bloodborne Pathogens (BBP) to 4 (Adm, Alt Adm/Alt DON, MSW, CH) of 7 active employees whose personnel records were reviewed. This deficient practice has the potential to place the Hospice’s employees and patients at risk for exposure to communicable and infectious diseases. --- The findings included: Record review of the OSHA, 29 (CFR) Part 1910.1030 and Appendix A relating to BBP, with a revised date 04/16/25, quoted in part, “(g)(2)(i) The employer shall train each employee with occupational exposure in accordance with the requirements of this section. Such training must be provided at no cost to the employee and during working hours. The employer shall institute a training program and ensure employee participation in the program…(ii) Training shall be provided as follows…(A) at the time of initial assignment to tasks where occupational exposure may take place…. (B) at least annually thereafter… (iv) Annual training for all employees shall be provided within one year of their previous training…(v) Employers shall provide additional training when changes such as modification…” Record review of the Hospice’s policies titled, “Infection Control Program IC.10”, with a revised date 03/01/24, quoted in part, “The infection program will include…Educating patients, caregivers, and staff on all related policies and procedures…V. Education…A. Employees…1. Upon hire and annually thereafter, all Hospice employees will be educated regarding the policies and procedures related to…” \Record review of an “Employee Roster” provided by the Adm upon entrance on 04/07/25 documented the hire dates for the following employees: ·       Adm with a hire date 03/14/24 ·       Alt Adm/ADON with a hire date 03/14/24 ·       MSW with a hire date 09/04/24 ·       CH with a hire date 06/17/23 Record review of Adm personnel file included an “Application for Employment” signed and dated 03/17/20. Further record review of the Adm personnel file included an “Orientation Program” signed and dated 03/17/20. Record review of the Adm personnel file included a “Job Description/Performance Evaluation” signed and dated 01/08/24. Record review of the Adm personnel file included an “In-service Record for Year 2024” that documented infection control trainings completed in January, February, and March that included “Infection Control Program, Bloodborne Pathogen Program and TB/Airborne Pathogen Program”. Record review of Adm personnel file failed to document any BBP/IC trainings within one year from previous training from March 2024 through April 2025 as required by Hospice policy and OSHA guidelines. Record review of the Alt Adm/ADON personnel file included a “Job Description/Performance Evaluation” signed and dated 03/14/24. Further record review of the Alt Adm/ADON personnel file included a “Job Description” signed and dated 06/15/22 that documented a “risk of exposure to BBP – high”. Record review of the Alt Adm/ADON personnel file included an “Orientation Checklist”, signed and dated 01/01/24, that documented orientation to agency “safety/OSHA…Exposure Control…Standard Precautions, Hepatitis B…Infection Control…” Record review of the Alt Adm/ADON personnel file included an “In-service Record for 2023 that documented infection control trainings completed in January, February, and March that included “Infection Control Program, Bloodborne Pathogen Program and TB/Airborne Pathogen Program”. Record review of the Alt Adm/ADON personnel file failed to document any infection control trainings within one year from previous training in January 2024 through April 2025 as required by Hospice policy and OSHA guidelines. Record review of the MSW personnel file included a “Job Application” signed and dated 08/23/24. Record review of the MSW personnel file failed to document any infection control trainings upon initial as required by Hospice policy and OSHA guidelines.Record review of CH personnel file included a “Chaplain/Spiritual/Pastoral Counselor Job Description” signed and dated 12/23/19. Further record review of CH personnel file included a “Bloodborne Pathogen and an Infection Control” training signed and dated 12/26/23. Record review of CH personnel file included an “Hospice Orientation Checklist” signed and dated 12/23/19. Record review of CH personnel file included a “Performance Appraisal/Evaluation….” signed and dated 12/26/23.  Record review of the CH personnel file failed to document any BBP/IC trainings within one year from previous training in January 2024 through April 2025 as required by Hospice policy and OSHA guidelines.In an interview on 04/07/25 at 03:00 p.m., the Adm stated the Agency had no active clients and had placed staff on standby. The Adm stated the DON was not available for interview at the moment and that she was the one who was responsible for providing infection control trainings. The Adm stated BBP/IC in-services were documented in personnel records in the employee’s in-service log. The Adm stated the DON was who had documentation of infection control trainings and was not sure what guidelines she followed to instruct staff regarding infection control. In a simultaneous record review and interview on 04/08/25 at 10:00 a.m., the Adm confirmed her date of hire of 03/17/20. The Adm stated there was no annual BBP/IC training in her personnel file. The Adm stated the last BBP training completed was an unknown date in February 2024. The Adm confirmed a date of hire for Alt Adm/ADON of 03/14/24. The Adm stated the Alt Adm/ADON personnel file contained no documentation of BBP/IC since his start date. The Adm stated the Alt Adm/ADON last BBP/IC training documented was an unknown date in March 2023. In a simultaneous record review and follow up interview on 04/14/25 at 02:45 p.m., the Adm confirmed a date of hire for the MSW of 09/24/24. The Adm stated she did not see a BBP/IC training upon hire documented in her personnel record. The Adm confirmed a date of hire for the CH of 06/17/23. The Adm stated the CH personnel record had no documentation of BBP/IC training for 2024. The Adm confirmed the MSW and CH both visited with patients and were at risk of exposure to infections. The Adm stated the personnel records reviewed including the Adm, Alt Adm/ADON, MSW and CH were not complete or up to date on BBP/IC trainings and therefore not following Hospice policies. The Adm stated this could have a negative effect because staff could contract something or cause infections. In an interview on 04/15/25 at 10:30 a.m., the DON stated BBP/IC trainings were conducted as reported per Hospice policy. The DON stated she was not quite sure how often BBP/IC trainings needed to be conducted at the Hospice. The DON presumed the Hospice performed BBP/IC trainings yearly and not so often. The DON stated, “I can’t remember when mine was last done, maybe mid last year 2024”. The DON stated the DON was responsible for conducting BBP/IC trainings. The DON stated the trainings had not been performed annually because the Hospice and the staff had been “back-to-back trying to get caught up and trying to get everyone on the same page”. The DON stated having staff in-serviced on BBP/IC could potentially minimize infections and it was “very important to stay updated with the reports”.  No additional information was provided by Hospice upon exit.

Based on record review and interview, the Hospice failed to provide at least 12 hours of in-service training during each 12-month period for 1 (Hospice Aide B) of 1 hospice aide whose record was reviewed. This failure could place the Hospice’s clients at risk of harm if staff have not been adequately trained to ensure they are providing adequate care. --- Findings included: Record review of an “Employee Roster” with no date noted provided upon entrance by the Adm documented Hospice Aide B with title of “CNA” and a hire date of 10/08/22. Record review of personnel record for Hospice Aide B included an “Application for Employment” signed and dated 12/13/19. Further record review of the personnel record included a “Hospice/Home Health Aide Job description: signed and dated 12/13/19. Record review of Hospice Aide B personnel record included a “Hospice Orientation Checklist’ signed and dated 12/23/19. Record review of personnel record included an “Annual Onsite Competency” signed and dated 12/18/23, that documented Hospice Aide B demonstrated competency all tasks evaluated on. Record review of personnel record included a training list of topics for year 2022 that had documented the following trainings completed in January “emergency preparedness plan, infection control plan…, exposure control, TB exposure control, and emergency preparedness”.  Record review of personnel record for Hospice Aide B failed to include documentation of at least 12 hours of in-service for 2022, 2023 and 2024. In a simultaneous record review and interview on 04/07/25 at 03:00 p.m., the Adm confirmed the date of hire for Hospice Adie B was 12/13/29 and not 10/08/22. The Adm stated the personnel record did not contain documentation for any hours of in-service. The Adm stated she was not sure who was responsible for providing the in-service and was not sure how often the in-service was supposed to be done. The Adm stated she was not sure what the policy for the Hospice Aide in-service was. The Adm stated the DON was not available. The Adm stated all staff including the DON was on standby because the Agency had no active clients. The Adm stated not having staff in-serviced could have a negative effect on potential clients because the Agency would not know if the staff was able to provide adequate care. In an interview on 04/15/25 at 10:30 a.m., the DON stated she did not have Hospice Aide B’s personnel record available for record review. The DON stated she was not sure when the last 12-hours of in-service for Hospice Aide B had been completed. The DON stated she was responsible for providing that training. The DON stated this training was completed yearly and that she needed to catch up this year. The DON stated she was aware of the difference of the computer-based trainings and the 12-hours of in-service required for hospice aides. The DON stated the hospice aide was required to “turn in computer-based trainings”. Record review of Hospice’s policies titled, “Agency in-services HR.65”, with a revised date 08/04/23, quoted in part, “The Hospice will provide ongoing in-service continuing education programs which are appropriate to job responsibilities and to the maintenance of necessary skills…B. All Hospice Aides are required to have at least 12 hours of in-service training during each 12-month period. Training may be based on the individual’s employment anniversary as long s the in-service training required is met…”Record review of Hospice’s policies titled, “Agency in-services HR.65-TX”, with a revised date 09/01/23, quoted in part, “In addition to the requirements defined in the Agency In-services policy in the Human Resources section of the Administrative Policy Manual, the following will apply…B. The Hospice aides will follow and comply with the state’s in-service requirements… C. Hospice Aide Training…1. All Hospice Aides are required to have at least 12 hours of in-service training during each 12-month period….2. The Hospice may provide Hospice Aide in-service training supervised by a Registered Nurse (RN) while the aide is providing care to a patient…3 The RN must document the exact skill or theory taught in the patient’s residence and the duration of the training… 4. The in-service training provided in the patient’s residence must not be a repetition of a hospice aide’s competency in basic skill…”.

Based on record review and interview, the Governing Body and Administrator (Adm) failed to organize and direct the day-to-day operations of the Hospice’s ongoing functions as follows: The Adm failed to ensure 4 (Adm, Alt Adm/ADON, CH, Hospice Aide B) of 7 employees whose personnel records were reviewed, received annual performance evaluations on their anniversary dates of hire for one of three years reviewed 2024.The Adm failed to ensure the Hospice’s written emergency preparedness and response plan (ERP) failed to include a continuity of operations plan that patient populations, but not limited to a risk; types of services the Hospice has the ability to provide in an emergency; delegation of authority and how to return to normal operations as quickly as possible for 1 of 1 plan reviewed.  The Adm failed to ensure the Hospice’s written emergency preparedness and response plan (ERP) failed to complete an internal review of the plan at least annually and after each actual emergency response for 2 (2022 and 2023) of 3 years reviewed. The Adm failed to ensure the Hospice failed to maintain a Quality Assessment Performance Improvement (QAPI) program for 1 (2024) of 3 years reviewed in that: the Hospice did not maintain a QAPI program implemented by its QAPI committee that reviewed, updated, or revised the plan of implementation at least once within a calendar year, or more if needed for 2024. --- These failures resulted in no administrative oversite and placed the hospice patients at risk of A/N/E, harm, and unmet needs during an emergency and/or disaster and prevented the hospice from identifying potential problems and implementing corrective actions to ensure the health and safety of the patients.Findings included: 1.      Record review of Hospice’s policies titled, “ Personnel/ Volunteer Performance Evaluations HR.50”, with a revised date 10/01/21, quoted in part, “The Hospice will establish a consistent process utilizing objective, measurable criteria for assessing the Hospice’s staff and volunteers demonstrated ability to achieve the expectations stated in respective job descriptions, to identify individual growth needs, and to implement an improvement plan, as needed… Formal performance evaluations will be performed and documented annually…” Record review of an Employee Roster provided upon entrance on 04/07/25 by the Adm documented an employee start date for the following employees:·       Adm – Start date 03/14/24 ·       Alt Adm/ADON – Start date 03/14/24 ·       CH – Start date 10/10/22 ·       Hospice Aide B – 10/08/22 Record review of the Adm personnel file included an “Application for Employment” and an “Orientation Program” checklist signed and dated 03/17/20. Record review of the Adm personnel file included a “Job Description/Performance Evaluation” signed and dated 01/08/24. Record review of the Adm personnel file failed to include a Job Description/Performance Evaluation within one year of the previous performance evaluation for 2024.Record review of the Alt Adm/ADON personnel file included an “Employer New Hire Reporting Form” that documented a date of hire of 01/01//24. Record review of the Alt Adm/ADON included a “Job Description/Performance Evaluation…Job title: Alternate page 1 of 2)”, no signature or date noted. Record review of the Alt Adm/ADON included a “Job Description/Performance Evaluation…Job title Alternate” signed and dated 03/14/24. Record review of the Alt Adm/ADON included a “Job Description” signed and dated 06/15/22. Record review of the Alt Adm/ADON included an “Orientation Checklist” signed and dated 01/01/24. Record review of the Alt Adm/ADON included a “Performance Evaluation, Title of Position: Registered Nurse…” signed and dated 06/18/23 and a “90-day performance evaluation” signed and dated 05/15//22. Record review of the Alt Adm/ADON personnel file failed to include a Job Description/Performance Evaluation within one year of the previous performance evaluation for 2024. Record review of the CH personnel file included a “Chaplain/Spiritual/Pastoral Counselor Job Description” signed and dated 12/23/19. Further record review of the CH personnel file included a “Hospice Orientation Checklist” signed and dated 12/23/19. Record review of the CH personnel file included an “Initial Competency: Chaplain/Spiritual Counselor” signed and dated 12/16/22. Record review of the CH personnel file included a “Performance Appraisal/Evaluation” signed and dated 12/26/23. Record review of the CH personnel file failed to include a Job Description/Performance Evaluation within one year of the previous performance evaluation for 2024. Record review of Hospice Aide B personnel file included an “Application for Employment” and a “Hospice/Home Health Aide Job Description” signed and dated 12/23/19. Record review of Hospice Aide B’s personnel file included a “Hospice Orientation Checklist” signed and dated 12/23/19. Record review of Hospice Aide B’s personnel file included a “Performance Appraisal/Evaluation: Hospice Aide” and an “Annual Onsite Competency: Hospice Aide” signed and dated 12/18/23. Record review of Hospice Aide B personnel file failed to include a “Performance Appraisal/Evaluation: Hospice Aide” within one year of the previous performance evaluation for 2024. In a simultaneous record review of personnel records and interview on 04/07/25 at 03:00 p.m., the Adm confirmed the date of hire for Hospice Aide B was 12/13/29 and not 10/08/22. The Adm confirmed the performance evaluation for Hospice Aide was on 12/18/23. The Adm stated there was no documentation of an updated performance evaluation for the Hospice Aide and that the personnel file was incomplete and inaccurate. The Adm stated that due to the Hospice not having any active patients, performance evaluations had not been completed because the Hospice had placed the staff on stand-by and was not actively seeing patients.  The Adm stated the Agency had discharged all clients in January 2024. The Adm stated the DON assisted in performing evaluations on clinical staff but was not available for interview. The Adm stated the previous Adm had last performed evaluations prior to his expiration in 2023 and no one had completed evaluations since then. The Adm the Hospice was not following Hospice policies by not performing annual evaluations and had potential negative effects on patients if staff was not evaluated in providing adequate care, trained, or educated. In a follow up interview and simultaneous record review of personnel records on 04/08/25 at 10:00 a.m., the Adm confirmed a date of hire for the Adm was 03/17/20 and not 03/14/24. The Adm confirmed there was not a job performance evaluation documented in the Adm personnel file. The Adm confirmed the last performance evaluation documented for the Adm was 01/08/24 and stated, “it is not complete and inaccurate”. The Adm confirmed the hire date for the Alt Adm/ADON was 03/14/24. The Adm confirmed a job description/performance evaluation signed upon hire and no documentation of a performance evaluation since that documented date in the Alt Adm/ADON personnel file. The Adm stated she was not sure why there were a lot of components missing in the Alt Adm/ADON personnel file, but the file was incomplete and inaccurate.  In a simultaneous record review of personnel records and interview on 04/14/25 at 02:45 p.m., the Adm confirmed the date of hire for the CH was 06/17/23. The Adm stated she had not “reviewed the CH” personnel file. The Adm confirmed the last documented performance evaluation was on 12/26/23 and no updated performance evaluation had been documented since then in the CH personnel file. The Adm stated the CH personnel file was not complete and was inaccurate. In an interview on 04/15/25 at 10:30 a.m., the DON stated the RN is responsible for performing hospice aides and clinical-staff annual evaluations. The DON stated she had not completed any annual evaluations on clinical staff for 2024. The DON stated she had been trying to “catch up with hospice and trying to help with home health” in their transition that she had been unable to perform annual evaluations. The DON stated annual performance evaluations should be done “upon hire and yearly”. The DON stated “prior to this year” evaluations have not been completed. Record review of the Hospice emergency preparedness and response binder included an “Emergency Preparedness Plan and Procedure”, not signed and reviewed 01/31/24, that documented “Recovery…Activities implemented during and after a disaster that are designed to return the Hospice to its normal operations as quickly as possible….Emergency Preparedness Plan and Procedure Checklist…Develop the Emergency Preparedness Plan…include mitigation, disaster response and recovery activities for clinical and administrative operations…Complete the Continuity Business Plan to ensure Quick recovery of the Business (Hospice…” signed and dated 01/09/23. Record review the Hospice ERP binder included a “Continuity of Operations Business Plan” that documented “Continuity of Operations Business Plan for… [Hospice B] … address… [address to Hospice B] … completed by RN A and signed and dated on 01/31/24. Record review of Employee Roster provided upon entrance by Adm did not list the Alt Disaster Coordinator named on the Continuity Business Plan as an active employee. Record review of the Continuity of Operations Business Plan failed to address emergency financial needs, essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible for the Hospice.In a simultaneous record review of the Hospice’s ERP binder and “Emergency Preparedness Plan and Procedure” on 04/15/25 at 03:00 p.m., the Adm stated she had not really been involved in the Hospice’s Emergency Preparedness since being appointed Adm. The Adm stated the Hospice had no active patients at the moment. The Adm stated the Hospice put all the employees on standby temporarily. The Adm stated she was not sure who the Disaster Coordinator was, but after reviewing the Continuity of Operations Business Plan she stated RN A was. The Adm stated the Alt Disaster Coordinator was not active or employed. The Adm stated the Continuity of Operations Business Plan was not accurate or updated. The Adm stated the Continuity of Operations Business Plan was for Hospice B. The Adm stated RN A was employed by Hospice B and may have used their Continuity of Operations Business Plan when she was “helping me with all of this”. The Adm stated RN A did not update the Continuity of Operations Business Plan to reflect the Hospice’s information on the plan. The Adm stated RN A was not available for interview. The Adm stated she, herself, had not reviewed the emergency preparedness binder “until just now”. The Adm stated “it is really incorrect and not our thing”. The Adm stated the DON was not involved in the development of the Continuity of Operations Business Plan. The Adm stated she hired RN A to “be in charge of it”. The Adm stated the DON was “supposed to be “overseeing” RN A but “she was not”. The Adm stated the Hospice did not have a Continuity of Operations Business Plan. The Adm stated it was her responsibility to ensure the Hospice had a complete and accurate Emergency Preparedness Plan and Continuity of Operations Business Plan. The Adm stated she had no answer as to why this was not looked at. The Adm stated “a lot was going on…too much to put in place…no excuses…me not taking care of it…” The Adm stated the Hospice was not following its policy for emergency preparedness.Record review of the Hospice’s policies titled, “Emergency Preparedness and Response Plan EC.40”, with a revised date, 01/31/24, quoted in part, “The Hospice will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services. The plan will…C. Provide for continuity of patient care and business operations including delegations of authority and succession plans…VI Continuity of Business Operations Plan…Record review of the Hospice emergency preparedness and response binder included an “Emergency Preparedness Plan and Procedure” not signed and reviewed 01/31/24, that documented “Review and Revise…The Emergency Preparedness Plan, policies and procedures will be reviewed at least annually, after each actual emergency response to evaluate its effectiveness and is updated as needed…. As part of the annual internal review, the Hospice will test the response phase of the emergency preparedness and response plan in a planned drill, if not tested during an actual emergency response. The Hospice will complete the Hospice Emergency Preparedness Plan Evaluation form with input from the staff involved with the drill, exercise, or emergency event….” signed and dated 01/09/23. Record review the Hospice ERP binder included a “Hospice Emergency Preparedness Plan Evaluation” form, with no signature or date noted, that documented all tasks had been evaluated. Further review of the Hospice ERP binder included an “Inservice/Exercise Sign In List” signed and dated 01/15/24 that documented a “Full-scale Community-Based Exercise” was performed to Hospice B by RN A. Record review of Hospice ERP binder included a “Business Recovery Plan Checklist” signed and dated 01/08/24 that documented Hospice completed the recovery checklist. In a simultaneous record review of the Hospice’s ERP binder and “Emergency Preparedness Plan and Procedure” on 04/15/25 at 03:00 p.m., the Adm stated she had not really been involved in the Hospice’s Emergency Preparedness since being appointed Adm. The Adm stated the Hospice had no active patients at the moment. The Adm stated the Hospice put all the employees on standby temporarily. The Adm stated she was not sure who the Disaster Coordinator was, but after reviewing the Continuity of Operations Business Plan she stated RN A was. The Adm stated the Alt Disaster Coordinator was not active or employed. The Adm stated the Continuity of Operations Business Plan was not accurate or updated. The Adm stated the Continuity of Operations Business Plan was for Hospice B. The Adm stated the Hospice had not performed any internal reviews of the Emergency Preparedness and Response plan since 2023. The Adm stated RN A was not available for interview. The Adm stated she, herself, had not reviewed the emergency preparedness binder “until just now”. The Adm stated “it is really incorrect and not our thing”. The Adm stated the DON was not involved in the development of the Continuity of Operations Business Plan or the internal review of the emergency response system. The Adm stated she hired RN A to “be in charge of it”. The Adm stated the DON was “supposed to be “overseeing” RN A but “she was not”. The Adm stated she had no answer as to why this was not looked at. The Adm stated “a lot was going on…too much to put in place…no excuses…me not taking care of it…” The Adm stated the Hospice was not following its policy for emergency preparedness.Record review of the Agency’s policies titled, “Emergency Preparedness and Response Plan EC.40”, with a revised date, 01/31/24, quoted in part, “The Hospice’s will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases and its approach to a disaster that could affect the need for its services or its ability to provide those services. The plan will…E Be reviewed and updated, including related policies and procedures, at least every two years…” Record review of the Agency’s policies titled, “Emergency Preparedness and Response Plan EC.40-TX”, with a revised date 07/0123, quoted in part, “The following will replace Policy II.E statement in the Emergency Preparedness and Response Plan policy in the Environmental/Safety/Equipment Management section of the Administrative Policy Manual, in reference to the review and update frequency of every two years…A. The Hospice will complete an internal review of the Emergency Preparedness and Response Plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed….”  Record review of the Hospice’s QAPI binder included a “Quality Assurance Performance Improvement Plan (2023) and (2022)”. Record review of the Hospice’s QAPI binder included “Quality Assessment and Performance Improvement (QAPI) Quarterly” reports and “Quality Assessment Improvement (QAPI) Committee Meeting Minutes” for 2023 and 2022 dated as follows: ·       04/11/22, 07/21/22, 01/02/23, 04/14/23, 07/14/23, and 10/09/23. Record review of the Hospice’s QAPI binder failed to include documentation that the QAPI program was implemented, reviewed, updated, or revised by the QAPI committee during 2024.In an interview on 04/14/25 at 02:10 p.m., the Adm stated, “Nothing has been done for QAPI for year 2024”. In a subsequent interview and simultaneous record review on 04/14/25 at 03:45 p.m., the Adm stated she did not know the answer to who the QAPI committee was. The Adm stated she did not know when the last time QAPI committee had a meeting. The Adm stated she was not sure who was part of the QAPI committee but thought it might include a RN, LVN, MSW, CH, and herself, the Adm. The Adm stated she was not sure how many times QAPI was supposed to meet but believed it was 2 times per year per the Hospice’s policy. The Adm stated the Hospice did not meet in 2024. The Adm stated she did not know she was responsible for the oversight of the QAPI or what the purpose of it was. The Adm stated she had a RN A helping her run the Hospice, but all the staff was currently on standby because there were no active patients. The Adm stated “we did not get that far [catch up with all required tasks including QAPI]”. The Adm stated the hospice has not had any meetings since 2023 and that could have a “pretty” negative impact to the Hospice and patients. The Adm stated, “that is why the Hospice is in the situation we are in right now”. The Adm stated the Hospice was not following its policy regarding QAPI and that it was her responsibility for the oversight of it.In an interview on 04/15/25 at 10:45 a.m., the DON stated the role of the DON in QAPI was to “help improve the quality care for the clients and to lead”. The DON stated the Agency had not maintained QAPI program in the past year but had “improved in quality”. The DON stated the Agency had not focused on QAPI because they had been “working to explain everything [transition in electronic medical record system] to the staff”.Record review of the Hospice policies titled, “Quality Assessment Performance Improvement Program QAPI.5”, with a revised date 10/01/21, quoted in part, “The Hospice will define, implement and maintain an effective, ongoing, hospice-wide data driven QAPI plan that is evaluated, reviewed, and updated or revised annually or more often if needed, by the QAPI Committee…” In an interview on 04/08/25 at 09:05 a.m., the Hospice Owner stated she was the “owner on paper, but the Adm was who was in command over the entire Hospice and its functions. Record review of the Hospice policies titled, “Responsibilities of the Administrator LD.25”, with a revised date 10/01/21, quoted in part, “The Hospice Administrator will assume overall responsibility and authority for the administrative and leadership functions, supervision of the establish organizational plan, and responsibility for ongoing communication with the Governing Body, as well as the Hospice staff…I. The Responsibilities of the Administrator may include, but are not limited to…A. Day-to-day operations of the Hospice…”Record review of the Hospice policies titled, “Responsibilities of the Administrator LD.25-TX”, with a revised date 04/14/23, quoted in part, “In Addition to the requirements defined in the Responsibilities of the Administrator policy in the Leadership section of the Administrator Policy Manual, the following requirements will be met…A. The responsibilities of the Administrator include but are not limited to: 1. Administratively supervise the provision of quality care to hospice patients…2. Supervise to ensure implementation of hospice policy and procedures…4 Employ or contract with qualified personnel…. 5. Ensure adequate staff education and evaluations…”

Based on record review and interview, the Hospice failed to ensure all staff followed Hospice policy and accepted standards of practice to ensure clinical record documentation was complete, accurate, signed and dated for 7 (Patient #1, Patient #4, Patient #5, Patient #9, Patient #12, Patient #13, Patient #14) of 14 patients whose records were reviewed. This failure has the potential to delay care, prevented the Hospice from ensuring patient’s services are provided as ordered, and placed Patients at risk of harm. --- The findings included: Record review of the Texas Administrative Code (TAC), Title 22 Examining Boards Part 11 Texas Board of Nursing Chapter 217. Licensure, Peer Assistance and Practice Section §217.11.Standards of Nursing Practice, accessed on 04/22/25,: “…The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization… Standards Applicable to All Nurses…shall… Know and conform to the Texas Nursing Practice Act and the boards rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse’s current area of practice…Accurately and completely report and document…” Record review of the TAC §558.301 (a)(9)(D) Client Records, accessed on 04/22/25,: “Each client record must include the following elements as applicable to the scope of services provided by the agency…clinical and progress notes. Such notes must be written the day service is rendered and incorporated into the client record within 14 working days. Record review of Agency policies titled, “Timelines IM.40”, with a revised date 10/01/21, quoted in part, “The Hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations…All Hospice staff, physician(s) and/or non-physician practitioner(s) and physician office staff as appropriate will be oriented to the following parameters… All medical record information will be incorporated into the patient’s medical record in a timely manner…” Record review of Agency policies titled, “Timelines-Addendum IM.40-TX”, with a revised date 04/14/23, quoted in part, “In addition to the requirements defined in the Timelines policy in the Information Management section of the Administrative Policy Manual, the following requirement will be met…All clinical and progress notes will be written the day service is rendered and incorporated into the patient’s medical record within 14 working days. During an entrance conference interview on 04/07/25 at 04/07/25 at 01:40 p.m., the Adm stated the Hospice had switched electronic medical record (EMR) system recently due to cost savings. The Adm stated they Hospice would provide access to both EMR systems for patient record review. Record review of Patient #1’s EMR included a “Patient Profile” that documented a start of care (SOC) date of 07/09/24, a primary diagnosis of “Alzheimer’s disease with early onset (degenerative brain disorder that slowly affects memory, thinking, learning, cognitive abilities, and behavior)”. Record review of Patient #1’s EMR included a “Hospice Plan of Care (POC)” signed and dated 08/27/24 that documented a certification period of 07/09/24 through 10/06/24 and the following orders: ·       Skilled nurse (SN) frequency: 2 visits per week for 1 week (2w1), 1 visit per week for 4 weeks (1w4) starting 07/09/24·       SN PRN (as needed) visits: 3 for decline in condition, change to medication, regimen, symptom management ·       Services accepted, RN, Spiritual, MSW (medical social worker) Record review of Patient #1’s EMR included the following SN visits: ·       07/09/24 signed and dated 07/26/24 that documented a “SN assessment” visit.·       07/10/24 signed and dated 07/28/24 that documented a “RN regular” visit Record review of Patient #1’s SN notes failed to be authenticated and dated within 14 working days in accordance with the TAC and Hospice policy. Record review of Patient #4’s EMR included a “General Patient Details” that documented a SOC date of 11/14/24 and a primary diagnosis of “chronic ischemic heart disease, unspecified (heart damage due to less blood and oxygen flow caused by narrowed arteries)”. Record review of Patient #4’s EMR included a POC signed and dated 01/12/25 that documented an effective date of 11/14/24 and the following orders: ·        SN: 1 visit(s) weekly, 1 PRN (as needed visit(s) every 30 day(s) Record review of Patient #4’s EMR included the following SN visits: ·       11/14/24 signed and dated 12/02/24 that documented a “RN – admission initial and comprehensive assessment” visit. ·       11/15/24 signed and dated 12/01/24 that documented a “SN- routine assessment” visit. ·       11/28/24 signed and dated 01/11/25 that documented a “RN – routine comprehensive assessment with supervision” visit. ·       12/12/24 signed and dated 01/16/25 that documented a “RN – routine comprehensive assessment with supervision” visit. ·       12/26/24 signed and dated 01/16/25 that documented a RN – routine comprehensive assessment with supervision” visit. Record review of Patient #4’s SN notes failed to be authenticated and dated within 14 working days in accordance with the TAC and Hospice policy. Record review of Patient #5’s EMR included a “General Patient Details” that documented a SOC date of 12/10/24 and a primary diagnosis of “Alzheimer’s disease with early onset). Record review of Patient #5’s EMR included a POC signed and dated 12/10/24 that documented an effective date of 12/10/24 and the following orders: ·       SN: 1 visit(s) weekly and 1 prn (as needed) visit(s) every 30 days Record review of Patient #5’s EMR included the following SN visits: ·       12/10/24 signed and dated 01/07/25 that documented a “RN – admission initial and comprehensive assessment” visit. ·       12/24/24 signed and dated 01/11/25 that documented a “RN – comprehensive assessment with supervision” visit. ·       12/31/24 signed and dated 01/09/25 that documented a “SN – routine assessment” visit. Record review of Patient #5’s SN notes failed to be authenticated and dated within 14 working days in accordance with the TAC and Hospice policy. Record review of Patient #9’s EMR included a “General Patient Details” that documented a SOC date of 04/18/24 and a primary diagnosis of “malignant neoplasm of unspecified part of left bronchus or lung (left lung cancer”. Record review of Patient #9’s EMR included a POC signed and dated 01/12/25 that documented an effective date of 12/14/24 and the following orders: ·       Skilled nurse visit: 1 visit(s) weekly) Record review of Patient #9’s EMR included the following SN visits: ·       12/12/24 signed and dated 01/11/25 documented a “RN Recertification” visit. ·       12/26/24 signed and dated 01/16/25 documented a “RN – routine comprehensive assessment with supervision” visit Record review of Patient #9’s SN notes failed to be authenticated and dated within 14 working days in accordance with the TAC and Hospice policy.  Record review of Patient #12’s EMR included a “General Patient Details” that documented a SOC date of 11/13/24 and a primary diagnosis of “chronic obstructive pulmonary disease, unspecified (lung or airway disease that restrict breathing)”. Record review of Patient #12’s EMR included a POC signed and dated 01/12/25 that documented an effective date of 11/13/24 and the following orders: ·       SN: 2 visit(s) weekly Record review of Patient #12’s EMR included the following SN visits: ·       11/14/24 signed and dated 12/01/24 that documented a “SN routine assessment” visit. ·       11/27/24 signed and dated 01/11/25 that documented a “RN routine comprehensive assessment with supervision” visit.·       12/11/23 signed and dated 01/17/25 that documented a “RN routine comprehensive assessment with supervision” visit. ·       12/15/24 signed and dated 01/17/25 that documented a “RN routine comprehensive assessment with supervision” visit. Record review of Patient #12’s SN notes failed to be authenticated and dated within 14 working days in accordance with TAC and Hospice policy.  Record review of Patient #13’s EMR included a “General Patient Details” that documented a SOC date of 12/13/24 and a primary diagnosis of “chronic obstructive pulmonary disease, unspecified (COPD). Record review of Patient #13’s EMR included a POC signed and dated 01/13/25 that documented an effective date of 12/14/24 and the following orders: ·       SN: 2 times per week for 1 week, 1 time a week, week 2 beginning 12/15/24. Record review of Patient #13’s EMR included the following SN visits: ·       12/13/24 signed and dated 01/13/25 that documented a “RN – admission initial and comprehensive assessment” visit ·       12/27/24 signed and dated 01/13/25 that documented a “RN – routine comprehensive assessment with supervision” visit Record review of Patient #13’s SN notes failed to be authenticated and dated within 14 working days in accordance with TAC and Hospice policy. Record review of patient #14’s EMR included a “General Patient Details” that documented a SOC date of 11/27/24 and a primary diagnosis of “Alzheimer’s disease (degenerative brain disorder that slowly affects memory, thinking, learning, cognitive abilities, and behavior)”. Record review of Patient #14’s EMR included a POC signed and dated 11/27/24 effective 11/27/24, that documented the following orders: ·       SN: 2 visit(s) weekly Record review of Patient #14’s EMR included the following SN visits: ·       11/27/24 signed and dated 01/10/25 that documented a “RN – admission initial and comprehensive assessment” visit.·       12/23/24 signed and dated 01/16/25 that documented a “RN – routine comprehensive assessment with supervision” visit. Record review of Patient #14’s SN notes failed to be authenticated and dated within 14 working days in accordance with TAC and Hospice policy.In a telephone interview on 04/15/25 at 10:30 a.m., the DON presumed the Hospice’s policy to authenticate, sign and enter notes completed into the electronic medical chart was 7 days. The DON stated there was no documentation that showed the reason why RN A was late on her documentation. The DON stated the RN A who had signed the nurse’s notes was behind on her notes. The DON stated there was no excuse why RN A was late on her documentation, but the Hospice had changed their software and the nurse had been “updating the charts”. The DON stated the RN A was the same nurse who was responsible for reviewing notes to ensure they were signed in a timely manner. The DON stated the Hospice did send reminders to sign notes in a timely manner. The DON stated RN A was working on “updating the charts”. The DON stated RN A had to “go through QA and she was getting reminders that they had to be completed”. The DON stated not signing notes in a timely manner affected client care and the other “practices” involved. The DON stated the notes “must be done in a timely manner”. The DON stated if assessments did not get signed in a timely manner, clients could potentially not get a revised plan of care. The DON stated, “there would be “no official plan of care in a timely manner”. The DON stated it was the DON and the Adm’s responsibility to ensure nurse’s notes were signed in a timely manner. In a continuation of the telephone interview with the DON and record review of patient charts, on 04/15/25 at 10:45 a.m., the DON confirmed a SOC date for Patient #13 as 12/13/24 and a certification period of 12/13/24 through 03/12/25. The DON stated visit note dated 12/13/24 was a comprehensive admission assessment and signed on 01/13/25.  The DON stated visit note 12/27/24 was signed on 01/13/25. The DON stated both entries were signed beyond the allowed timeframe per Hospice policy and considered late. The DON confirmed a SOC date for Patient #9 as 04/18/24 and a certification period of 12/14/24 through 02/11/24. The DON confirmed visit note 12/12/24 was signed 01/11/25 and visit note 12/26/24 was signed 01/16/25. The DON stated both entries were entered by RN A, signed beyond the allowed timeframe per Hospice policy and considered late. The DON stated there was no documentation to justify why these notes were late. The DON confirmed a SOC date for Patient #14 as 11/27/24 and a certification period of 11/27/24 through 02/24/25. The DON confirmed visit notes 11/27/24 was signed 01/10/25 and visit note 12/23/24 was signed 01/16/25. The DON stated both entries were entered by RN A, signed beyond the allowed timeframe per Hospice policy and considered late.  The DON confirmed a SOC for Patient #5 as 12/10/24 and a certification period of 12/10/24 through 03/09/25. The DON confirmed visit notes 12/10/24, an initial comprehensive assessment, was signed on 01/07/25, visit note 12/24/24 was signed on 01/11/25, and visit note 12/31/24 was signed on 01/09/25. The DON stated all entries were signed beyond the allowed timeframe per Hospice policy and considered late. The DON confirmed a SOC for Patient #12 as 11/13/24 and a certification period of 11/13/24 through 01/09/25. The DON confirmed visit notes 11/14/24 signed 12/01/24, 11/27/24 signed 01/11/25, 12/11/23 signed 01/17/25 and 12/15/25 signed 01/17/25 were all signed beyond the allowed timeframe per Hospice policy and considered late.  The DON confirmed a SOC for Patient #4 as 11/14/24 and a certification period of 11/14/24 through 01/13/25. The DON confirmed visit note 11/14/24 signed 12/02/24 was an admission initial comprehensive assessment. The DON confirmed visit notes 11/15/24 was signed 12/01/24, 11/28/24 was signed 01/11/25, 12/12/24 was signed 01/16/25 and 12/26/24 was signed 01/16/25. The DON stated all notes for Patient #4 discussed were signed beyond the allowed timeframe per Hospice policy and considered late. The DON stated there was no documentation to justify the reason why these notes were late. The DON stated patients could have a negative impact if initial assessments were not signed in a timely manner because care could be delayed. The DON stated the DON and Adm had oversight to ensure these entries were signed in a timely manner. In an interview on 04/15/25 at 12:45 p.m., the Adm stated RN A was not available for interview. The Adm stated she did not know the Hospice’s policy regarding the timeframe clinical notes needed to be entered into the patient’s record. The Adm stated the DON was responsible for clinical duties including ensuring clinical notes were signed and entered in a timely manner. The Adm stated RN A had been assisting primarily in these duties during the Hospice’s transition. No additional information was provided by the time of exit on 04/15/25 at 04:10 p.m.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment; This standard was not met as evidenced by clinical record review and interview. 11 of 11 (100%) records reviewed revealed that an individual emergency plan was not documented as part of the patient/family comprehensive assessment. Record #29010 was reviewed and identified that the patient elected the hospice benefit on 11/18/2021. There was no individual emergency plan documented in the clinical record. Record #85751 was reviewed and identified that the patient elected the hospice benefit on 6/11/2021. There was no individual emergency plan documented in the clinical record. Record #95974 was reviewed and identified that the patient elected the hospice benefit on 6/11/2020. There was no individual emergency plan documented in the clinical record. Record #71746 was reviewed and identified that the patient elected the hospice benefit on 9/4/2021. There was no individual emergency plan documented in the clinical record. Record #38413 was reviewed and identified that the patient elected the hospice benefit on 11/17/2021. There was no individual emergency plan documented in the clinical record. Record #95154 was reviewed and identified that the patient elected the hospice benefit on 10/25/2021. There was no individual emergency plan documented in the clinical record. Record #24503 was reviewed and identified that the patient elected the hospice benefit on 1/21/2020. There was no individual emergency plan documented in the clinical record. Record #47913 was reviewed and identified that the patient elected the hospice benefit on 6/28/2021. There was no individual emergency plan documented in the clinical record. Record #40184 was reviewed and identified that the patient elected the hospice benefit on 6/16/2021. There was no individual emergency plan documented in the clinical record. Record #38530 was reviewed and identified that the patient elected the hospice benefit on 3/17/2021. There was no individual emergency plan documented in the clinical record. Record #69802 was reviewed and identified that the patient elected the hospice benefit on 12/21/2021. There was no individual emergency plan documented in the clinical record. In an interview with the Administrator on 2/9/2022, she agreed that the individual emergency plan was not in the clinical record. She stated that each patient had an emergency plan in the folder in the patient's home but were not uploaded into the individual clinical records. She had no additional information to provide.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: characteristics of the pain, including: location, frequency, and intensity. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) records reviewed revealed that the pain assessment did not addresses all aspects of the patient's pain. Record #29010 was reviewed and identified that the patient elected the hospice benefit on 11/18/2021. The initial pain assessment completed on 11/18/2021 revealed that the patient had pain but did not identify the location of the pain. In an interview with the Administrator on 2/9/2022, she agreed that the location of the pain was not identified in the assessment, and she had no additional information to provide.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs. The 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. 1 of 11 (9%) records reviewed revealed that the drug profile was not updated. Record #95974 was reviewed and identified that the patient elected the hospice benefit on 6/11/2020. In an IDG note from the most recent recertification completed on 2/5/22 the nurse stated that the patient was on 02 at 3-4lpm. The O2 was not present on the medication profile. In an interview with the Administrator on 2/09/2022 she confirmed that the O2 was not present on the medication profile and had no additional information to provide.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including intervention to manage pain and symptoms. This standard was not met as evidenced by 2 of 11 (18%) clinical records reviewed revealed that the Plan of Care (POC) did not include required elements. Record #29010 was reviewed and identified that the patient elected the hospice benefit on 11/18/2021. The initial assessment completed on 11/18/2021 indicated that the patient had pain but did not indicate the location of the pain. The location of the patient's pain was also not identified in the plan of care. The initial assessment completed on 11/18/2021 documented in part, "Large plaque of erythematous tissue on vulva extending and incorporation the entirety of the R labia majora, the inferior mons pubis superior to the clitoris extending along the superior aspect of the labia majora." The plan of care did not identify skin integrity impairment as a problem. Record #71746 was reviewed and identified that the patient elected the hospice benefit on 9/4/2021. In an IDG note on 2/1/22, the nurse stated in part, "Patient has an unstageable wound to to her Right heel." There was no problem for skin integrity identified on the plan of care. In an interview with the Administrator on 2/9/2022, she agreed that the plan of care did not include the required items and had no additional information to provide.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) applicable discharged records for patients that revoked hospice services reviewed revealed that the discharge summary was not sent to the patent's attending physician. Record #40184 was reviewed and revealed that the patient was discharged due to revocation on 9/26/2021. A discharge summary was completed, but there was no documentation provided to the primary care physician. Record #38530 was reviewed and revealed that the patient was discharged due to no longer meeting eligibility requirements on 6/14/2021. A discharge summary was completed, but there was no documentation provided to the primary care physician. In an interview with the Administrator on 2/9/2022, she confirmed that there was no documentation to support the discharge summary sent to the primary care physician and had no additional information to provide.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) applicable records reviewed of patients residing in a SNF revealed that the plan of care did not specify which provider is responsible for performing the functions that were agreed upon and included in the plan of care. Record #71746 was reviewed and indicated that the patient elected the hospice benefit on 9/4/2021. The latest plan of care updated during IDG on 2/2/2022 did not indicate the interventions which the Nursing Facility was responsible for providing. Record #95154 was reviewed and indicated that the patient elected the hospice benefit on 10/25/2021. The latest plan of care updated during IDG on 2/2/2022 did not indicate the interventions which the Nursing Facility was responsible for providing. In an interview with the Administrator on 2/9/2022, she agreed that the interventions did not contain any identified responsibilities of the Nursing Facility. She felt that this may be an area of focus with the EMR provider to ensure the capability to identify facility staff as a responsible party. She had no additional information to provide.