Every finding on record at Healthcare California Hospice

Based on interview and record review, the agency failed to comfort Patient 1 and the family member when Registered Nurse/Case Manager (RN/CM) 1 did not contact the family member back for four hours to assist Patient 1's need of the medication for nausea. This failure placed Patient 1 at extended discomfort from nausea and Patient 1's family member at emotional distress. --- During a concurrent  interview and record review  on 7/9/25 at 2:30 p.m., with the Director of Patient Care Services (DPCS),  Patient 1's "Patient Communication " note dated 6/13/25 was reviewed.  The "Patient communication" note indicated, "On 6/12/25: son was requesting a call from nurse for a question. This nurse had re-literate many times to call the office for question and not staff directly as we are busy doing patient visits. I was unable to make the call until 4 ours later..."  The DPCS stated no matter what the situation was, RN/CM 1 shouldn't have Patient 1's family member wait four hours to get a call back.  The DPCS stated it was the agency's philosophy to support patients and family's needs in a  timely manner.  The DPCS stated if RN/Cm 1 was tied up she should ha call the DPCS to coordinate the care needed. During a phone interview on 7/10/25 at 8 a.m., RN/CM 1 stated the agency currently utilize "group text" within the team members to share the issues.  RN/CM 1 stated the first text was at 10 a.m.. but she did not check her text till 4 pm and learned  Patient 1 needed for mediation to relieve nausea & vomiting.  The RN/CM 1 stated the current communication was not effective.  RN/CM 1 stated Patient 1 and the family member were not supported to their optimal comfort due to inefficient communication.  RN/CM 1 stated she assumed other discipline saw the group text and responded to Patient 1's family member's question. During a review of the agency's "Hospice Admission Booklet", dated 12/22, the "Hospice Admission Booklet" indicated, "Section 1. Welcome, Mission and Philosophy...Hospice helps the terminally ill person maintain quality of life and helps family members through an extremely stressful time in their lives."During a review of the agency's job title "Director of Patient Care Services (DPCS)". dated 10/19, the jo title "DPCS " indicated, "Coordinate and oversees all direct and indirect patient services provided y clinical organization personnel."During a review of the agency's job title "Clinical Supervisor (CS)", the job title "CS" indicated, "The clinical supervisor is responsible for ensuring that care and services are delivered appropriately and for the supervision of clinical personnel."

It is required that the hospice EP [Emergency Preparedness] training program includes the following, for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by personnel record review and interview. In 3 of 10 (30%) personnel records reviewed, the organization did not ensure Emergency Preparedness training was completed at the time of hire and at least every two (2) years. Personnel Record 1: Registered Nurse date of hire 12/15/2023. The nurse was assigned emergency preparedness training in the organization's online learning platform in December of 2023; however, it was still marked incomplete as of the date of record review on 03/06/2024. Personnel Record 6: Contracted Medical Director contract date 06/26/2020. The personnel record contained no documented evidence of EP training for 2021, 2022, 2023, or 2024 as of the date of record review on 03/06/2024. During joint personnel record review with the Office Manager on 03/06/2024, it was revealed that the contracted provider did not have a profile set up with the agency's online training platform. Personnel Record 7: Nurse Practitioner date of hire 02/10/2017. The personnel record contained no documented evidence of EP training for 2021, 2022, 2023, or 2024 as of the date of record review on 03/06/2024. During joint personnel record review with the Office Manager on 03/06/2024, it was revealed that the employee did not have a profile set up with the agency's online training platform. During joint personnel record review on 03/06/2024, the Office Manager and the Human Resources Business Partner confirmed that the Registered Nurse, Personnel Record 1 did not complete the assigned orientation education which included EP training. It was also confirmed that the Medical Director, Personnel Record 6 and the Nurse Practitioner, Personnel Record 7 did not receive EP training in 2021, 2022, 2023, or 2024 to date.

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. In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure the psychosocial assessment was completed as part of the comprehensive assessment. Clinical Record 7: The patient elected the hospice benefit on 06/27/2023. Clinical record review revealed the initial psychosocial assessment was scheduled to be completed by the Social Worker on 07/01/2023 as part of the initial comprehensive assessment. The clinical record included a missed visit note dated 07/04/2023 completed by the Social Worker that documented, "Patient passed away." The Social Worker did not complete an initial psychological assessment for the patient as part of the initial comprehensive assessment. Clinical Record 12: The patient elected the hospice benefit on 09/21/2023. Clinical record review revealed the initial psychosocial assessment was scheduled to be completed by the Social Worker on 09/27/2023 as part of the initial comprehensive assessment. The clinical record included a missed visit note dated 09/27/2023 completed by the Social Worker that documented, "Patient expired." The Social Worker did not complete an initial psychological assessment for the patient as part of the initial comprehensive assessment. During an interview and review of findings on 03/06/2023, the Administrator/Director of Patient Care Services (DPCS) confirmed that the records lacked evidence of an initial psychosocial assessment being completed as part of the comprehensive assessment. The Administrator/DPCS provided no explanation for the missing assessments stating that the Social Worker had time to complete the assessments prior to the patients passing.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure the comprehensive assessment included an initial bereavement assessment was completed. Clinical Record 7: The patient elected the hospice benefit on 06/27/2023 and passed away on 07/04/2023. Clinical record review revealed the initial bereavement assessment was scheduled to be completed by the Social Worker on 07/01/2023. The clinical record contained a missed visit note from the Social Worker dated 07/04/2023 that stated in part, "Patient passed away." The initial bereavement assessment was not completed as part of the comprehensive assessment at the start of care. Clinical Record 12: The patient elected the hospice benefit on 09/21/2023 and passed away on 09/27/2023. Clinical record review revealed the initial bereavement assessment was scheduled to be completed by the Social Worker 09/27/2023. The clinical record contained a missed visit note from the Social Worker dated 09/27/2023 that stated in part, "Patient expired." The initial bereavement assessment was not completed as part of the comprehensive assessment at the start of care. During an interview and review of findings on 03/06/2024, the Administrator/Director of Patient Care Services (DPCS) confirmed that the records lacked evidence of an initial bereavement assessment being completed as part of the comprehensive assessment. The Administrator/DPCS provided no explanation for the missing assessments stating that the Social Worker had time to complete the assessments prior to the patients passing.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records, interviews and joint record reviews with the Administrator/Director of Patient Care Services which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans in the following areas: Failure of the agency to ensure implementation of the individualized interdisciplinary plan of care [HCPC.19.I/L543]; Failure to ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care [HCPC.21.I/L548]; and Failure to ensure the Interdisciplinary Group reviewed, revised, and documented the individualized plan of care no less frequently than every 15 calendar days [HCPC.22.I/L552]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary group, care planning, and coordination of services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the 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, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the hospice did not ensure the implementation of the individualized interdisciplinary plan of care. Clinical Record 1: The patient elected the hospice benefit on 10/16/2023. The plan of care dated 10/16/2023 included an order for the Medical Social Worker (MSW) frequency of visits once a month with two as needed visits. Clinical record review revealed no documented evidence of MSW visits for the months of November 2023, December 2023, February 2024, and March 2024, as of the date of record review on 03/05/2024. The plan of care included an order for Physical Therapy once a quarter. The clinical record contained no documented evidence of Physical Therapy visits from the election of benefit on 10/16/2023 through the date of record review on 03/05/2024. During an interview and review of findings on 03/07/2024, the Administrator/Director of Patient Care Services (DPCS) confirmed that the organization did not ensure implementation of the plan of care related to the frequency of MSW and Physical Therapy visits. The Administrator/DPCS stated that she believes the family called and requested only for the nurse to visit the patient, however this was never confirmed prior to the exit conference on 03/07/2024.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the hospice did not ensure that the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 10/16/2023. The plan of care dated 10/16/2023 included a nutrition goal for the patient that stated, "Patient maintains adequate nutrition and hydration." The goal statement was not measurable when it did not define how adequate nutrition and hydration would be measured for the patient. Clinical Record 3: The patient elected the hospice benefit on 04/01/2023. The plan of care dated 04/01/2023 included a nutrition goal for the patient that stated, "Patient maintains adequate nutrition and hydration." The goal statement was not measurable when it did not define how adequate nutrition and hydration would be measured for the patient. Clinical Record 4: The patient elected the hospice benefit on 04/11/2023. The plan of care dated 04/11/2023 included a nutrition goal for the patient that stated, "Patient maintains adequate nutrition and hydration." The goal statement was not measurable when it did not define how adequate nutrition and hydration would be measured for the patient. Clinical Record 5: The patient elected the hospice benefit on 04/13/2023. The plan of care dated 04/13/2023 included a nutrition goal for the patient that stated, "Patient maintains adequate nutrition and hydration." The goal statement was not measurable when it did not define how adequate nutrition and hydration would be measured for the patient. Clinical Record 11: The patient elected the hospice benefit on 09/19/2023. The plan of care dated 09/19/2023 included a goal related to the patient’s suprapubic catheter that stated, "Patient maintains optimal urinary elimination." The goal statement did not define how optimal urinary elimination would be measured for the patient. During an interview and review of findings on 03/06/2024, the Administrator/Director of Patient Care Services (DPCS) confirmed that the goal statements were lacking measurability. The Administrator/DPCS stated that the hospice staff should be defining how to measure what is adequate or optimal for each patient.

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 no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the hospice did not ensure that the Interdisciplinary Group (IDG) reviewed, revised, and documented the individualized plan of care no less frequently than every 15 calendar days. Clinical Record 3: The patient elected the hospice benefit on 04/01/2023. Clinical record review revealed no documented evidence of an IDG meeting or plan of care review from 06/20/2023 through 07/13/2023, a total of 23 days without review of the plan of care. Clinical Record 4: The patient elected the hospice benefit on 04/11/2023. Clinical record review revealed no documented evidence of an IDG meeting or plan of care review from 06/20/2023 through 07/13/2023, a total of 23 days without review of the plan of care. Clinical Record 5: The patient elected the hospice benefit on 04/13/2023. Clinical record review revealed no documented evidence of an IDG meeting or plan of care review from 06/20/2023 through 07/28/2023, a total of 28 days without review of the plan of care. During an interview and review of findings on 03/06/2024, the Administrator/Director of Patient Care Services (DPCS) confirmed that the records were missing evidence of POC review/revision at least every 15 days. The Administrator/DPCS stated that the review was likely scheduled on 07/04/2023 but was missed for a holiday. The Administrator also stated that the review should have been rescheduled for the day prior, 07/03/2023, or the day after, 07/05/2023, but could offer no explanation of why this did not occur as they were not working with the organization at the time.

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 and use of gloves. This standard was not met as evidenced by document review, observation, and interview. In 1 of 1 (100%) home visit observation, the hospice did not ensure the clinician followed organizational policy related to hand hygiene and use of gloves. Organizational policy number 7-009 (Revised May 2023) stated in part, "hand decontamination using an alcohol-based hand rub should be performed after removing gloves." Home Visit 1: During the home visit observation with the Registered Nurse (staff 1), the nurse was observed to remove an old dressing and cleansed the wound with gloves on. The nurse then removed the dirty gloves and without sanitizing hands, donned a clean pair of gloves. The wound was then packed, and the clinician again removed gloves and did not sanitize their hands as required by agency policy. During this same visit and on another wound, the clinician, with gloved hands, again removed the dressing and cleansed the wound. The nurse then removed the dirty gloves and without sanitizing hands, donned a clean pair of gloves to continue the wound care. During the daily wrap up meeting on 03/06/2024 with the Administrator/Director of Patient Care Services (DPCS), the home visit observation and organization's hand hygiene policy were discussed. The Administrator/DPCS confirmed that the lack of hand hygiene by the nurse (Staff 1) after removing gloves, did not comply with organizational policy.

It is required that the infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 3 of 10 (30%) personnel records reviewed, the hospice did not ensure infection control education was completed by employees and contracted providers. Personnel Record 1: Registered Nurse date of hire 12/15/2023. The nurse was assigned infection control education within the organization's online learning platform upon hire. During a joint personnel record review with the Office Manager on 03/06/2024, it was revealed that the assigned education was marked "not complete" within the online learning platform. The employee record contained no documented evidence that the nurse had completed infection control education. Personnel Record 6: Contracted Medical Director date of contract 06/26/2020. The personnel record contained no documented evidence of infection control education for 2021, 2022, or 2023. During a joint personnel record review with the Office Manager on 03/06/2024, it was discovered that the contracted provider did not have a profile set up with the agency's online learning platform. Personnel Record 7: Nurse Practitioner date of hire 02/10/2017. The personnel record contained no documented evidence of infection control education for 2021, 2022, or 2023. During a joint personnel record review with the Office Manager on 03/06/2024, it was revealed that the employee did not have a profile set up with the agency's online learning platform. During a joint personnel record review with the Office Manager and the Human Resources Business Partner on 03/06/2024, it was confirmed that the Registered Nurse, Personnel Record 1 did not complete the assigned orientation education which included infection control. It was also confirmed that the Medical Director, Personnel Record 6 and the Nurse Practitioner, Personnel Record 7 did not receive infection control education in 2021, 2022, or 2023.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by personnel record review and interview. In 2 of 9 (22%) personnel records reviewed, the organization did not ensure licensed professionals participated in hospice sponsored in-service training. Personnel Record 6: Contracted Medical Director date of hire 06/26/2020. Personnel record review revealed no documented evidence of participation in hospice sponsored in-service training for 2021, 2022, 2023, or 2024, as of the date of record review on 03/06/2024. During a joint personnel record review with the Office Manager on 03/06/2024, it was revealed that the contracted provider did not have a profile set up with the agency's online training platform. Personnel Record 7: Nurse Practitioner date of hire 02/10/2017. Personnel record review revealed no documented evidence of participation in hospice sponsored in-service training for 2021, 2022, 2023, or 2024, as of the date of record review on 03/06/2024. During a joint personnel record review with the Office Manager on 03/06/2024, it was revealed that the employee did not have a profile set up with the agency's online training platform. During a joint personnel record review and interview on 03/06/2024, the Office Manager and Human Resources Business Partner stated the organization utilizes an online learning and training platform for their in-service training. Both staff members identified did not have profiles created within the platform therefore were presumed by the Office Manager to have not participated in hospice sponsored in-service training. This was also acknowledged by the Administrator/Director of Patient Care Services (DPCS).

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records and interviews with the Administrator/Director of Patient Care Services which revealed issues with the agency's aide services, which included: Failure to ensure the hospice aide provided services as ordered by the IDG (Interdisciplinary Group) and included in the plan of care [HCDT.16.I/L626]; and Failure to ensure hospice aides were supervised by a Registered Nurse making an on-site visit to the patient’s home no less frequently than every 14 days [HSRM.25.I/L629]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.76: Hospice aide and homemaker services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group (IDG) and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide provided services as ordered by the IDG and included in the plan of care. Clinical Record 7: The aide plan of care dated 06/27/2023 assigned the aide the visit frequency of twice a week. Clinical record review revealed the aide provided one visit the week of 06/25/2023, on 06/27/2023. A hospice aide missed visit note on 06/30/2023, stated in part, "CHHA [certified home health aide] unavailable. On temporary leave." The agency did not ensure the patient was provided with aide visits twice a week as ordered on the aide plan of care. Clinical Record 14: The aide plan of care dated 09/26/2023 assigned the aide the visit frequency of twice a week. Clinical record review revealed the aide provided four visits the week of 10/01/2023 and seven visits for the week of 10/08/2023. The record contained no documented evidence to indicate why additional aide visits were needed or that a physician order was obtained for the additional visits. During an interview and review of findings on 03/06/2024, the Administrator/Director of Patient Care Services (DPCS) confirmed that the records included aide visits inconsistent with ordered frequencies. The Administrator/DPCS provided no explanation stating she was not working with the organization at the time and was unaware why there are inconsistencies. Related to missing visits for Clinical Record 7, the Administrator/DPCS stated there should have been another hospice aide available to furnish the ordered hospice aide visits rather than missing the visit because one hospice aide was on leave.

It is required that hospice aides are supervised by a Registered Nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed with aide services provided, the organization did not ensure hospice aides were supervised by a Registered Nurse making an on-site visit to the patient’s home no less frequently than every 14 days. Clinical Record 3: The patient elected the hospice benefit on 04/01/2023. The patient was receiving hospice aide services twice weekly per the hospice aide plan of care dated 04/01/2023. Clinical record review revealed no documented evidence of aide supervision by a Registered Nurse from 04/10/2023 through 04/25/2023 a total of 15 days, from 07/03/2023 through 07/18/2023 a total of 15 days, from 07/18 2023 through 08/08/2023 a total of 21 days, and 08/08/2023 through 08/24/2023 a total of 16 days. Clinical Record 14: The patient elected the hospice benefit on 09/26/2023. The patient was receiving hospice aide services twice weekly per the hospice aide plan of care dated 09/26/2023. Clinical record review revealed no documented evidence of aide supervision by a Registered Nurse from 10/18/2023 through 11/08/2023 a total of 21 days. During an interview and review of findings on 03/06/2024, the Administrator/Director of Patient Care Services (DPCS) confirmed that the records lacked evidence of the hospice aide being supervised by an on-site visit from the Registered Nurse no less frequently than every 14 days. The Administrator/DPCS provided no explanation for the missing supervision and stated they were not working with the organization at the time.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Review of the volunteer binder with the Volunteer Coordinator on 03/07/2024 revealed reports of volunteer hours and calculations for percentage of volunteer hours to patient care hours by hospice staff for 2023 and 2024. The reports of volunteer hours documented zero (0) total for volunteer hours and subsequent 0% for the percentage of volunteer hours related to direct patient care hours of paid hospice employees. During an interview on 03/07/2024 the Volunteer Coordinator acknowledge that the agency is to have a 5% minimum requirement for volunteer hours. The Volunteer Coordinator stated that she was recently hired and is working towards meeting the minimum requirements for this standard.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, personnel record review, and interview. In 7 of 10 (70%) personnel records reviewed, the agency did not ensure staff that provided care to agency patients had completed the initial and/or ongoing skills competencies as required by agency policy. Organizational policy number 3-001 (Revised October 2019) stated in part, "The organization will establish and annually evaluate a group of specific skills related to patient care/services responsibilities and complexity of care/service provided by personnel. Competencies must be successfully demonstrated before organization personnel complete orientation." Personnel Record 1: Registered Nurse date of hire 12/15/2023. Personnel record review revealed no documented evidence that the employee completed an initial competency assessment. Personnel Record 3: Home Health Aide date of hire 07/24/2023. Personnel record review revealed no documented evidence that the employee completed an initial competency assessment and no evidence of the state skills competency quiz for the home health aide. Personnel Record 4: Chaplain and Bereavement Coordinator date of hire 03/01/2022. Personnel record review revealed no documented evidence that the employee completed an initial competency assessment for the role of Chaplain role and the role of Bereavement Coordinator. The personnel record included no documented evidence that annual competency assessments were completed for the role of Chaplain and the role of Bereavement Coordinator role for 2023 or 2024, as of the date of record review on 03/06/2024. Personnel Record 5: Medical Social Worker date of hire 06/12/2014. Personnel record review revealed no documented evidence that the employee completed annual competencies for 2021, 2022, 2023, or 2024, as of the date of record review on 03/06/2024. Personnel Record 7: Nurse Practitioner date of hire 02/10/2017. Personnel record review revealed no documented evidence that the employee completed annual competencies for 2021, 2022, 2023, or 2024, as of the date of record review on 03/06/2024. Personnel Record 8: Volunteer Coordinator date of hire 09/21/2023. Personnel record review revealed no documented evidence that the employee completed an initial competency assessment. Personnel Record 9: Physical Therapist date of hire 08/27/2018. Personnel record review revealed no documented evidence that the employee completed annual competencies for 2021, 2022, 2023, or 2024, as of the date of record review on 03/06/2024. During a joint personnel record review and interview on 03/06/2024, the Office Manager and the Human Resources (HR) Business Partner confirmed that the personnel records lacked evidence of initial or annual competencies. The Office Manager stated that she is new to the organization and is still trying to get all the personnel files organized and find the required documents within their online HR platform. The HR Business Partner stated she would continue to look for the documents, however none were produced before the exit conference on 03/07/2024.

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. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records and interviews with the Administrator/Director of Patient Care Services which revealed issues with the agency's clinical records in the following areas: Failure to ensure the receiving facility was forwarded the hospice discharge summary [HCDT.38.I/L682]; Failure to ensure the attending physician was forwarded a copy of the hospice discharge summary [HCDT.39.I/L683]; Failure to ensure the patient’s clinical record included completed advanced directives [HSIM.3.I/L677]; and Failure to ensure the clinical record included a completed hospice election statement [HSIM.3.I/L673]. The cumulative effect of these deficiencies has resulted in the hospice organization'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 care and services from the agency.

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 signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed, the agency did not ensure the clinical record included a completed hospice election statement. Clinical Record 2: The patient elected the hospice benefit on 03/07/2023. Clinical record review revealed the Consent for Election of Medicare Hospice Benefit signed 03/07/2023, indicated the patient elected to receive the Patient Notification of Noncovered Items, Services, and Drugs. The record included no documented evidence that the patient was provided with information on non-covered items. Clinical Record 3: The patient elected the hospice benefit on 04/01/2023. Clinical record review revealed the Consent for Election of Medicare Hospice Benefit signed 04/01/2023, indicated the patient elected to receive the Patient Notification of Noncovered Items, Services, and Drugs. The record included no documented evidence that the patient was provided with information on non-covered items. Clinical Record 4: The patient elected the hospice benefit on 04/11/2023. Clinical record review revealed the Consent for Election of Medicare Hospice Benefit signed 04/11/2023, indicated the patient elected to receive the Patient Notification of Noncovered Items, Services, and Drugs. The record included no documented evidence that the patient was provided with information on non-covered items. Clinical Record 5: The patient elected the hospice benefit on 04/13/2023. Clinical record review revealed the Consent for Election of Medicare Hospice Benefit signed 04/13/2023, indicated the patient elected to receive the Patient Notification of Noncovered Items, Services, and Drugs. The record included no documented evidence that the patient was provided with information on non-covered items. Clinical Record 7: The patient elected the hospice benefit on 06/27/2023. Clinical record review revealed the Consent for Election of Medicare Hospice Benefit signed 06/27/2023, indicated the patient elected to receive the Patient Notification of Noncovered Items, Services, and Drugs. The record included no documented evidence that the patient was provided with information on non-covered items. Clinical Record 9: The patient elected the hospice benefit on 07/13/2023. Clinical record review revealed the Consent for Election of Medicare Hospice Benefit signed on 07/13/2023 did not include the hospice start of care date, it was left blank. Clinical Record 14: The patient elected the hospice benefit on 09/26/2023. Clinical record review revealed the Consent for Election of Medicare Hospice Benefit signed 09/26/2023, indicated the patient elected to receive the Patient Notification of Noncovered Items, Services, and Drugs. The record included no documented evidence that the patient was provided with information on non-covered items. During an interview and joint record review on 03/06/2024, the Administrator/Director of Patient Care Services confirmed that the records lacked evidence of completed election statements and/or requested addendums.

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 any advance directives. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the patient’s clinical record included completed advanced directives. Clinical Record 2: The patient elected the hospice benefit on 03/07/2023. The initial nursing assessment dated 03/07/2023 included documentation that stated, "Patient is a DNR [Do Not Resuscitate]." The Physician Orders for Life-Sustaining Treatment (POLST) with no date was signed by the patient on 03/07/2023, but did not include a signature of the physician, nurse practitioner, or physician assistant and was therefore incomplete. Clinical Record 12: The patient elected the hospice benefit on 09/21/2023. The initial nursing assessment on 09/21/2023 included documentation that stated, "Patient is a DNR." The clinical record did not include evidence of a Physician Orders for Life-Sustaining Treatment (POLST). During an interview and review of clinical records on 03/06/2023, the Administrator/Director of Patient Care Services (DPCS) confirmed that the records lacked evidence of completed POLST forms despite identifying the patients as DNRs.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed with patient transfer, the hospice did not ensure the receiving facility was forwarded the hospice discharge summary. Clinical Record 3: The patient elected the hospice benefit on 04/01/2023 and transferred to another hospice agency on 10/16/2023. The discharge summary dated 10/16/2023 indicated the patient "transferred to another hospice agency" however the box that indicated communication and hand off to the receiving facility was left unchecked. The record provided no evidence that the discharge summary was provided to the receiving hospice agency. Clinical Record 4: The patient elected the hospice benefit on 04/11/2023 and revoked hospice care to pursue aggressive treatment on 09/26/2023. The discharge summary dated 09/26/2023 included documentation that stated, "pt [patient] is revoked from hospice and will now need to be seen by [his/her] PCP [primary care physician] after [his/her] hospital admission." The box indicating communication and hand off to the receiving facility/hospital was left unchecked. The record provided no evidence that the discharge summary was provided to the receiving hospital. Clinical Record 8: The patient elected the hospice benefit on 07/13/2023 and transferred to another hospice agency on 07/28/2023. A discharge live nursing note dated 07/28/2023 included documentation that stated, "Family request to have pt [patient] transferred to a different hospice agency." Clinical record review revealed no documented evidence that a discharge summary was sent to the receiving hospice agency. During an interview and review of findings on 03/06/2024, the Administrator/Director of Patient Care Services (DPCS) confirmed that the records lacked evidence that discharge summary had been forwarded to the receiving facilities. The Administrator/DPCS stated this was likely due to the hospice staff being unaware of how to properly document communication with the receiving facilities but cannot confirm as she was not working with the organization at the time.

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 standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed where the patient revoked the hospice benefit, the hospice did not ensure the attending physician was forwarded a copy of the hospice discharge summary. Clinical Record 5: The patient elected the hospice benefit on 04/13/2023 and was discharged as no longer terminally ill on 10/09/2023. A discharge note completed by the Registered Nurse dated 10/09/2023 included documentation that the patient was no longer terminally ill and stated in part, "pt [patient] will be transferred to home health services." Clinical record review revealed no documented evidence the hospice discharge summary was provided to the patient's attending physician. During an interview and review of findings on 03/06/2023, the Administrator/Director of Patient Care Services (DPCS) confirmed that the record lacked evidence of a discharge summary being forwarded to the attending physician. The Administrator/DPCS stated that the patient was likely referred to the hospice organization's sister company, a home health agency, and the hospice staff didn't realize they needed to document the discharge summary being communicated to the new attending physician. However, this cannot be confirmed as the Administrator/DPCS was not with the organization at the time.