Every finding on record at High Desert Hospice

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. 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, interview and observation. In 1 of 2 (50%) home visit observations revealed the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 2: During Home Visit 2 (Clinical Record 5) on 10/24/2024 to observe the Registered Nurse (Personnel Record 6), the Hospice Director of Nursing was present. The hospice medication profile was compared to the assisted living facility (ALF) medications. The ALF medications included the following medication not listed on the hospice medication profile: Tramadol 50mg take one tablet every 6 hours as needed for pain. The hospice medication profile listed Tramadol 50mg take one-half tablet every 6 hours as needed for pain. A physician's order dated 03/22/2024 revealed a change to the Tramadol dose, discontinue Tramadol 50mg one-half tab, start Tramadol 50 mg one tab every 6 hours as needed for pain. There was no documented evidence that the new Tramadol dose of 50mg every 6 hours as needed for pain was updated to the hospice medication profile. During an interview and joint record review with the Director of Nursing on 10/24/2024, she stated, "I am not sure why the nurse did not update the hospice medication list with the new order, the medication list should have been updated when the Tramadol dose changed."

It is required that each patient’s individualized written plan of care contains 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 1 of 6 (17%) clinical records reviewed revealed the agency did not ensure the patient’s individualized written plan of care contained measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 2: The patient elected the hospice benefit on 10/17/2024 for the diagnosis of End-stage heart failure. The plan of care dated 10/17/2024 included a physical comfort problem with the goal, "patient will achieve and maintain optimal physical comfort". The plan of care did not define "optimal" nor include a measurable goal for the physical comfort problem. During an interview and joint record review with the Director of Nursing on 10/24/2024, she stated, "We have made progress on care plan goals but we are still working on them, they should not be using optimal as a goal because it's not measurable, the education is ongoing."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed revealed the agency did not ensure the written plan of care was updated by the physician. Clinical Record 5: The patient elected the hospice benefit on 11/27/2023 for the diagnosis of End-stage heart failure. The plan of care for the benefit period 08/23/2024-10/21/2024 did not include a physician's signature. There was no evidence that the clinical record included an updated plan of care. During an interview and joint record review with the Director of Nursing on 10/24/2024, she stated, "We discovered this week that this plan of care order was sent to the previous medical director so we sent it to the correct hospice medical director and it was signed today."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. 0 This standard was not met as evidenced by clinical record review, interview and observation. In 4 of 19 (21%) home visit observations revealed the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: During Home Visit 1(Clinical Record 1) on 09/10/2024 to observe the Registered Nurse (Personnel Record 5), the hospice medication list was compared to the skilled nursing facility (SNF) medication list. The SNF list included the following medication(s) not listed on the hospice list: Chloraseptic spray 4 times a day PRN (as needed) dated 08/07/2024. The hospice medication list included the following medication(s) not listed on the SNF list: Hydrocortisone cream, Zinc cream, and oxygen as needed, dated 08/22/2024. Home Visit 2: During Home Visit 2 (Clinical Record 2) on 09/10/2024 to observe the Hospice Aide (Personnel Record 8), the hospice medication list was compared to the assisted living facility (ALF) medication list. The ALF list included the following medication(s) not listed on the hospice list: Lorazepam 2mg/ml give 0.25 ml liquid dated 12/21/2024 as needed, and the hospice medication list had lorazepam 0.5 mg tablet as needed dated 6/22/2024. Upon review with the ALF Administrator, neither the Lorazepam liquid nor the tablet was available in the facility. She explained they "might have expired and been disposed of previously." The hospice medication list included the following medication(s) not listed on the ALF list: Zinc barrier cream as needed and oxygen at 5 liters per minute continuous dated 06/22/2024, both were in the facility but not on the medication list. Home Visit 3: During Home Visit 3 (Clinical Record 3) on 09/10/2024 to observe the Social Worker (Personnel Record 6), the hospice medication list was compared to the assisted living facility (ALF) medication list. Upon comparing the lists, the following discrepancy was identified: the ALF listed Haldol 0.5 ml every 4 hours as needed, and hospice listed Haldol 0.25 ml every 4 hours as needed. The hospice medication list contained the following medication(s) not listed on the ALF list: Zinc barrier cream as needed and oxygen as needed dated 08/08/2024, both were in the facility but not on the medication list. Home Visit 4: During Home Visit 4 (Clinical Record 4) on 09/11/2024 to observe the Licensed Practical Nurse (LPN) (Personnel Record 13), the hospice medication list was compared to the assisted living facility (ALF) medication list. The ALF list included the following medication(s) not listed on the hospice list: Abilify 5 mg daily dated 7/8/2024. The hospice medication list included the following medication(s) not listed on the ALF list: Zinc barrier cream and oxygen as needed. It was also noted that the insulin sliding scale parameters were noted to be different between the medication lists. Interviewed the LPN (Personnel Record 13) who is listed as the Assistant Director of Nursing for the Alternate Delivery Site regarding the medication reconciliation process. She advised the nurses "handwrite the medication orders and send them to the parent branch to be entered by a nurse in the office." During an interview and joint record review with the ALF Administrator on 09/10/2024, she advised the medication lists were printed by the pharmacy and if the "hospice didn't order medications directly from the pharmacy they had to be handwritten on a paper medication list (referring to the cream and oxygen)." During an interview and joint record review with the Director of Nursing (Personnel Record 4) and Alternate Director of Nursing on 09/10/2024, they advised those "medications should have been profiled through the pharmacy." During the interview regarding the lorazepam on Home Visit 2, the Alt DON advised patient had originally "gone into the ALF for respite and wasn't doing well so they had ordered liquid and later switched to tablets."

It is required that each patient’s individualized written plan of care contains 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 4 of 19 (21%) clinical records reviewed revealed the agency did not ensure the patient’s individualized written plan of care contained measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 5: The patient elected the hospice benefit on 05/14/2024 for the diagnosis of severe protein-calorie malnutrition. The plan of care dated 05/14/2024 included a nutrition problem: "patient will maintain optimal nutrition and hydration". The plan of care did not define "optimal" nor include measurable goals, interventions or outcomes for the patient. Clinical Record 9: The patient elected the hospice benefit on 08/17/2024 for the diagnosis of malignant neoplasm of the stomach. The plan of care dated 08/17/2024 included a Pain Problem, Interventions, and Goals that stated "Patient will achieve and maintain optimal physical comfort by time of death or discharge. Patient will have optimal pain level." The initial nursing assessment dated 08/17/2024 noted patient had "Pain level 3 and taking Tramadol for pain." The plan of care did not include a patient’s optimal pain level or a measurable goal for individualized pain level. Clinical Record 10: The patient elected the hospice benefit on 07/31/2024 for the diagnosis of malignant neoplasm of the breast. The plan of care dated 07/31/2024 included a Pain Problem, Interventions, and Goals that stated "Patient will achieve and maintain optimal physical comfort by time of death or discharge. Patient will have optimal pain level." The plan of care did not include a patient’s optimal pain level or a measurable goal for individualized pain level. Clinical Record 11: The patient elected the hospice benefit on 04/20/2022 for the diagnosis of malignant neoplasm of the lung. The plan of care dated 04/20/2022 included a Pain Problem, Interventions, and Goals that stated "Patient will achieve and maintain optimal physical comfort by time of death or discharge. Patient will have optimal pain level." The plan of care did not include a patient’s optimal pain level or a measurable goal for individualized pain level. During an interview and joint record review with the Director of Nursing (Personnel Record 4) on 09/10/2024, she advised she "put in most of the plans of care but realized how they needed more adjustments.” She advised they have recently contracted with a consulting group and "that will help with the plans of care".

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was revised as frequently as the patient's condition required. Clinical Record 3: The patient elected the hospice benefit on 08/08/2024 for the diagnosis of malignant neoplasm of the lung. The plan of care dated 08/08/2024 included a spiritual intervention to "provide empathetic listening" via monthly visits. Review of the clinical record revealed 2 on-call visits dated 08/20/2024 and 08/27/2024 for "spiritual distress". There was no documented evidence of any revisions to the plan of care. Clinical Record 5: The patient elected the hospice benefit on 05/14/2024 for the diagnosis of severe protein-calorie malnutrition. The plan of care dated 05/14/2024 included a Genitourinary Problem with interventions to "Assess urinary function" and the Goal "Patient will have optimal urinary elimination. " A nursing visit dated 05/16/2024 noted a Foley catheter was started and "chronic urinary issues". A nursing on-call visit dated 06/22/2024 noted the "Foley was leaking and patient continued to have issues with the Foley." There was no documented evidence of any revisions to the plan of care. Clinical Record 11: The patient elected the hospice benefit on 04/20/2022 for the diagnosis of malignant neoplasm of the lung. Pain Problem, Interventions, and Goals that stated "Patient will achieve and maintain optimal physical comfort by time of death or discharge. Patient will have optimal pain level." A nursing visit dated 08/06/2024 noted "Pain of 4. Increase of 3 Tramadol a day from 2." There was no documented evidence of any revisions to the plan of care. Clinical Record 12: The patient elected the hospice benefit on 05/28/2022 for the diagnosis of protein-calorie malnutrition. The nutrition plan of care dated 05/28/2022 stated "patient will have optimal nutrition." The nursing initial assessment noted MAC (mid-arm circumference) 19.8 cm on admission and the last nursing note dated 09/04/2024 noted the MAC to be 21 cm. There was no documented evidence of any revisions to the plan of care or explanations regarding the weight gain. Clinical Record 14: The patient elected the hospice benefit on 03/03/2024 for the diagnosis of scleroderma. The plan of care does not contain revisions regarding the wounds, although multiple physician orders have been documented regarding wound care. There was no documented evidence of any revisions to the plan of care. Clinical Record 17: The patient elected the hospice benefit on 07/06/2022 for the diagnosis of malignant neoplasm of the stomach. The plan of care dated 07/06/2022 included a Genitourinary Problem with interventions to "Assess urinary function" and the Goal "Patient will have optimal urinary elimination. " The patient was admitted to hospice services with a Foley catheter. The clinical record noted 2 PRN (as needed) visits for "leaking Foley" between 07/06/2022 and patient's death 07/14/2022. There was no documented evidence of any revisions to the plan of care. During an interview and joint record review with the Director of Nursing (Personnel Record 4) on 09/12/2024, she advised she put in the "plans of care but realized how many updates they needed"

It is required that licensed professional services provided directly or under arrangement are supervised only by appropriately qualified health care professionals who meet the appropriate qualifications specified under §418.114 and who practice under the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 1 (100%) personnel record reviewed in which licensed services were provided directly revealed the agency did not ensure the professional was appropriately qualified. A review of the organizational chart revealed the LPN (Personnel Record 13) directly supervising Registered Nurses, as it has a direct line from her to "All ADS Staff'. Personnel Record 13: Licensed Practical Nurse (LPN) with document and active license as an LPN. The title for this LPN was “Assistant Director of Nursing.” The personnel record contained a Director of Nursing Job Description that was signed by this LPN on 03/01/2024 and it included the following Job Summary: “Provides overall planning, direction, coordination, management and supervision of all nursing and professional services in conjunction with the Administrator. Qualifications and Experience: Must be a Registered Nurse in the State (Agency State); Nurse Accountability: Reports directly to the Administrator.” Furthermore, the job description had several areas where the Director of Nursing must "assess" and assessment is not part of a licensed practical nurse’s scope of practice or qualification. During a group interview on 09/12/2024 with the Director, Operations Manager, and Director of Nursing (parent site) the organization chart and job description were discussed. At one point, it was stated "what if we just change the organization chart and job description?" There was no acknowledgement that the LPN should not be supervising the RNs. A review of the organizational chart and Personnel Record 13 indicated the Agency did not ensure the Director of Nursing in the Alternative Delivery Site (ADS) met the requirements per licensure. The Director of Nursing in the ADS is per licensure a Licensed Practical Nurse. The Organizational Chart provided to the Site Visitor has the LPN directly supervising Registered Nurses, as it has a direct line from her to "All ADS Staff'. The signed job description in her personnel file dated 03/01/2024 under line 1 Qualifications lists "Must be a Registered Nurse in the State of New Mexico." The job description also has several areas where the Director must "assess" and assessment is not part of the licensed nurse ability or qualification.

It is required that the hospice clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient's attending physician and hospice staff. The clinical record may be maintained electronically. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure the clinical records were complete {HSIM.4.I/L679}; Failed to ensure he clinical patient record its content, and the information it contains is safeguarded against loss or unauthorized use and must be in compliance with the Department's rules regarding personal health information as set out at 45 CFR parts 160 and 164 {HSIM.I/L680}; Failed to ensure that the discharge summary was forwarded to the patient's attending physician {HCDT.39.I/L683}; and Failed to ensure the patient's discharge summary included at least the patient's current plan of care {HCDT/40. I/L684}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that All entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed revealed agency did not ensure the clinical records were complete. Clinical Record 4: A wound care order dated 09/10/2024 stated "Mupirocin apply 1 application to wound QD (every day) as directed". A wound care order dated 06/10/2024 stated "Metronidazole apply to wounds until s/s (signs and symptoms) of infection are gone." The orders did not specify the location of the wounds, who would perform the wound care, the frequency of the wound care or give any as needed orders for wound care. These were incomplete wound care orders. Clinical Record 5: A wound order dated 08/19/2024 stated "Cleanse with wound cleanse, pat dry with gauze, pack with idoform, packing strip, cover with 2x2 sterile gauze and optifoam, 3x weekly. A wound order dated 07/29/2024 stated "Cleanse wound with wound wash, pat dry, apply med honey, cover with optifoam. Provide wound care 3x week" The orders did not specify the location of the wounds, who would perform the wound care, the frequency of the wound care or give any as needed orders for wound care. They were incomplete wound care orders. Clinical Record 16: A wound care order dated 10/31/2023 stated "Clean affected area with wound cleaner, pat dry, apply dressing daily." The order did not specify the location of the wound, who would perform the wound care, the frequency of the wound care or give any as needed orders for wound care. It was an incomplete wound care order. Clinical Record 19: An order dated 07/10/2024 stated "Admit to GIP (general inpatient) for". The order did not include the symptom that needed to be managed for GIP and was not signed by a physician. During an interview and joint record review with the Director of Nursing on 09/12/2024, she advised "The nurses that wrote the wound orders were newer" and agreed the orders "were missing critical pieces."

It is required the hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by clinical record review, document review, interview and observation. In 7 of 19 (100%) clinical records revealed that the agency did not ensure the clinical patient record its content, and the information it contains is safeguarded against loss or unauthorized use and must be in compliance with the Department's rules regarding personal health information as set out at 45 CFR parts 160 and 164. Document 2: An employee agreement titled "HIPAA Confidentiality Agreement Statement (no date)" was signed and in all personnel files reviewed. It stated in relevant parts "Three Key Areas: Securing electronic transmissions, PHI basics, electronic storage. Utilization of personal electronic equipment makes data record keeping and retrieval easier and less time consuming, but this process carries with a higher risk for non-authorized access to patient confidential information. To comply with HIPAA requirements, meeting the trust needs of our patients, the following policies will be necessary: *Do not utilize public Wi-Fi connections* "No public or social media" Clinical Record 1: A physician order dated 08/22/2024 was sent to the agency from an agency clinician via a free public communication platform for sending text messages and pictures. It was then printed and placed into the patient's clinical record. Clinical Record 2: A physician order dated 06/22/2024 was sent to the agency from an agency clinician via a free public communication platform for sending text messages and pictures. It was then printed and placed into the patient's clinical record. Clinical Record 3: A physician order dated 08/08/2024 was sent to the agency from an agency clinician via a free public communication platform for sending text messages and pictures. It was then printed and placed into the patient's clinical record. Clinical Record 4: A physician order dated 06/10/2024 was sent to the agency from an agency clinician via a free public communication platform for sending text messages and pictures. It was then printed and placed into the patient's clinical record. Clinical Record 5: A physician order dated 08/19/2024 was sent to the agency from an agency clinician via a free public communication platform for sending text messages and pictures. It was then printed and placed into the patient's clinical record. Clinical Record 16: A physician order dated 06/10/2024 was sent to the agency from an agency clinician via a free public communication platform for sending text messages and pictures. It was then printed and placed into the patient's clinical record. Clinical Record 19: A physician order dated 07/10/2024 was sent to the agency from an agency clinician via a free public communication platform for sending text messages and pictures. It was then printed and placed into the patient's clinical record. During an interview with the Alt Administrator/Director on 09/12/2024, she confirmed they were using a free public communication platform for sending text messages and pictures to send protected health information. The Operations Director stated they started using it "based on information they gained during a survey". During an interview and joint record review on 09/11/2024, the Alt Director of Nursing advised clinicians utilize a free public communication platform for sending text messages and pictures to "send physician orders, medication updates, plan of care updates and other patient information from the alternate delivery site to the parent branch." During an interview with the Alt Administrator/Director on 09/12/2024, she confirmed they were using a free public communication platform for sending text messages and pictures to send protected health information. The Operations Director stated they started using it "based on information they gained during a survey". During an interview and joint record review on 09/11/2024 the Alt Director of Nursing advised they utilize a free public communication platform for sending text messages and pictures to send physician orders, medication updates, plan of care updates and other patient information from the alternate delivery site to the parent branch.

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. In 1 of 1 (100%) clinical record reviewed in which the patient revoked or was discharged for no longer being terminally ill revealed the agency did not ensure the discharge summary was forwarded to the patient's attending physician. Clinical Record 15: The patient elected the hospice benefit on 08/10/2023 for the diagnosis of Parkinson's disease. The patient elected to revoke hospice services on 02/05/2024. The clinical record did not contain evidence of the discharge summary being forwarded to the patient's attending physician. During an interview and joint record review with the Director of Nursing on 09/12/2024, she advised the discharge summary had not been faxed or sent to the attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; or any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed revealed the agency did not ensure the patient's discharge summary included at least the patient's current plan of care. Clinical Record 15: The discharge summary written 02/05/2024 when the patient elected to revoke hospice services stated, "Patient requested to be sent to palliative care then he will be moving." It did not include the patient's current plan of care. During an interview and joint record review with the Director of Nursing on 09/10/2024, she advised the discharge summary did not meet the requirements, but she had not previously been aware of the requirements.

It is required that short-term inpatient care must be available for pain control, symptom management, and respite purposes, and must be provided in a participating Medicare or Medicaid facility. THIS IS A CONDITON LEVEL DEFICIENCY. This condition was not met as evidenced by a review of clinical record, observations and interviews which revealed the hospice: Failed to ensure the respite was provided by a Medicare or Medicaid certified facility {HSIC.3.I/L709}; and Failed to ensure the respite was provided by facility that provides 24-hour nursing services that meet the needs of the patients {HSIC.4. I/L710} The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.108: Short-term inpatient care. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that hospice inpatient care for respite purposes is provided by a Medicare or Medicaid certified nursing facility that meets §418.110(f) (regarding home-like patient areas). This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed in which the patient was noted to have received respite services revealed the agency did not ensure the respite was provided by a Medicare or Medicaid certified facility. Clinical Record 2: The clinical record contained information that the patient was placed into "emergent respite" at an assisted living facility on 06/23/2024. Clinical Record 12: The clinical record contained a physician's order dated 07/08/2022 that stated, "Respite 5 days" and listed the name of an assisted living facility. Clinical Record 17: A social worker note dated 09/13/2023 noted "patient in assisted living facility (ALF) for respite so he can participate in MAID (medical aid in dying). During an interview with the Alt Administrator/Director on 09/10/2024, she stated, the SNF (skilled nursing facility) that they had a respite contract "often was full and did not have a respite bed available." She further went on to describe an incident where they had an emergent situation where the patient's husband had "to be hospitalized and they had to find a respite bed." She said the SNF was full, and they had to use the ALF. The Site Visitor asked for a contract for respite at one of the ALF and she was able to produce one the next day, but it did not have a business associate agreement attached. This contract showed to be executed in 2019. On this contract, it did not list a Medicare or Medicaid license. The Director did state she believed them to have a Medicaid license. On 09/12/2024, the Site Visitor made a visit to one of the ALF where respite had been provided and the contract that had been provided. An interview was conducted with the caregiver at the ALF. She called the owner on the phone during the conversation. There was not a posted copy of the license in the facility. The caregiver stated, "She was not a nurse and the other caregiver there was not a nurse, but several nurses stopped by the facility." When the Site Visitor asked about the nurses who stopped by, the caregiver stated, "they are from hospices who have patients here." A hand typed list was provided to the Site Visitor on 09/12/2024 for patients that had respite stays in 2024 which consisted of 24 patients in the parent branch. A list of respite patients was requested for 2023 however was not provided. The Director asked the Site Visitor if it would make a difference "if they hadn't billed for the respite stays."

It is required that the facility offering respite care provides 24-hour nursing services that meet the needs of the patients and each patient’s plan of care (POC). Each patient receives all nursing services as prescribed in the plan of care and is kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed in which the patient was noted to have received respite services revealed the agency did not ensure the respite was provided by facility that provides 24-hour nursing services that meet the needs of the patients. Clinical Record 2: The clinical record contained information that the patient was placed into "emergent respite" at an assisted living facility on 06/23/2024. Clinical Record 12: The clinical record contained a physician's order dated 07/08/2022 that stated, "Respite 5 days" and listed the name of an assisted living facility. Clinical Record 17: A social worker note dated 09/13/2023 noted "patient in ALF (assisted living facility) for respite so he can participate in MAID (medical aid in dying). During an interview with the Alt Administrator/Director on 09/10/2024, she stated, the SNF (skilled nursing facility) that they had a respite contract "often was full and did not have a respite bed available." She further went on to describe an incident where they had an emergent situation where the patient's husband had "to be hospitalized and they had to find a respite bed." She said the SNF was full, and they had to use the ALF. An interview was conducted with the caregiver at the ALF. She called the owner on the phone during the conversation. There was not a posted copy of the license in the facility. The caregiver stated, "She was not a nurse and the other caregiver there was not a nurse, but several nurses stopped by the facility." When the Site Visitor asked about the nurses who stopped by, the caregiver stated, "they are from hospices who have patients here." A hand typed list was provided to the Site Visitor on 09/12/2024 for patients that had respite stays in 2024 which consisted of 24 patients in the parent branch. A list of respite patients was requested for 2023 however was not provided. The Director asked the Site Visitor if it would make a difference "if they hadn't billed for the respite stays.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 13 (15%) personnel records reviewed revealed the agency did not ensure the personnel files contained a criminal background check on employees who have direct patient contact or access to patient records. Personnel Record 1: An employee (Medical Director) hired on 02/01/2024 who has direct patient contact or access to patient records did not have documentation of a criminal background check in his file. Per an interview with the Operations Manager on 09/09/2024 his "fingerprints were completed on 03/27/2024, however no clearance has been returned from the state as of this date." Personnel Record 12: An employee (Associate Medical Director) hired on 10/01/2022 who has direct patient contact or access to patient records did not have documentation of a criminal background check in her file. In an interview with the Operations Manager on 09/12/2024, the employee got her "fingerprints at the correctional facility but hasn't provided a copy, and the previous Director of Nursing for the Alternate Delivery Site was supposed to follow up."

Based on record review and interview the agency did not have a written communication protocol and documentation of communication with facilities for 1 (P [patient] 1) of 8 (P1 - P7, P9, and P10) patients reviewed for receiving hospice services in a facility. This deficient practice can lead to a breakdown in communication between the hospice, nursing home and patient caregivers that can result in poor outcomes for the patient. --- The findings are: A. Record review of agency document titled, ";Compliance Tool For Hospices That Provide Care to Residents of SNF/NF, ICF/IID Or Other Facility" stated, ";Written Agreement Must Include:. . . A provision regarding the manner in which the hospice and the facility will communicate with each other and how that communication will be documented. . . The hospice provides a copy of the plan of care, hospice election form. . . hospice contact information, how to access hospice staff 24/7 and hospice physician orders specific to the resident to the facility." B. Record review of the written agreement between the agency and [name of nursing facility] dated 07/30/2015 on page 3 stated, ";3.1.11 Hospice shall provide Facility with the following information immediately upon the information becoming available to Hospice: (1) the most recent hospice plan of care specific to each Patient under Hospices care; (2) each Patients hospice election form; (3) physician certification and recertification of the terminal illness specific to each Patient under Hospices care. . ." and on page 7 stated, ";3.3.13 Communication Protocol. Prior to the admission of any Patient to Hospice, Hospice and Facility shall work together to develop a written communication protocol governing how they will communicate all information needed for the Patients care (such as physician orders, and medication information), including how such communication will be documented to ensure that the needs of patients are addressed and met 24 hours a day. The communication protocol shall include, among other things, a procedure that clearly outlines the chain of communication between the parties in the event a crises or emergency develops, a change of condition occurs, and/or changes to the Hospice plan of care are indicated, and it must also address how hospice physician orders will be communicated to Facility staff. Such protocol shall be distributed to all Hospice and Facility Staff involved in the Patients care." C. Record review of P1s medical record maintained by the hospice agency did not reveal any documentation that the election benefit form, certification, recertifications, or updated plan of care was provided to the facility. D. Record review of P1s medical record maintained by the facility (nursing home) revealed there was no evidence in the record of the election benefit form, certification, recertifications, or updated plans of care from the hospice. E. During an interview on 11/07/2023 at 8:30 AM S (staff) 8, Director of Nursing for the nursing facility confirmed that they did not have a written protocol in place for communicating with the hospice. S8, also confirmed there was no documentation from the hospice in the patients chart or on-site at the facility. F. During an interview on 11/07/2023 at 9:00 AM, S5, RN (Registered Nurse) Case Manager was asked how they communicated with the facility (nursing home) staff, it was explained that they fill out a ";visit sheet" that includes vitals and updates, and they leave it at the desk for the nurses. G. During an interview on 11/08/2023 at 9:45 AM, S3, Director confirmed the agency did not have a written protocol in place for communicating with facilities (nursing home) where patients reside and confirmed there was not any documentation that the facility (nursing home) was provided with all necessary documents for patients care needs.

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 including 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 document review. 4 of 4 (100%) clinical records reviewed revealed the hospice did not ensure the patient was given information related to the election of hospice benefit addendum option to request at any time, in writing, the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Document 1: Policy #1-031, "Hospice Election Statement (Dated: April 2021)", stated in part, "Procedure: 4. The patient and family/caregiver, or his/her legal representative will be asked to sign the hospice election statement which acknowledges the following: F. The right to receive an election statement addendum, "Patient Notification of Hospice Non-Covered Items, Services, and Drugs". Clinical Record 1: The patient elected the hospice benefit on 8/17/22. The record lacked evidence of the patient/family having an option to request the Addendum, "Patient Notification of Hospice Non-Covered Items, Service, and Drugs." Clinical Record 2: The patient elected the hospice benefit on 10/31/22. The record lacked evidence of the patient/family having an option to request the Addendum, "Patient Notification of Hospice Non-Covered Items, Service, and Drugs." Clinical Record 3: The patient elected the hospice benefit on 12/30/22. The record lacked evidence of the patient/family having an option to request the Addendum, "Patient Notification of Hospice Non-Covered Items, Service, and Drugs." Clinical Record 4: The patient elected the hospice benefit on 11/19/22. The record lacked evidence of the patient/family having an option to request the Addendum, "Patient Notification of Hospice Non-Covered Items, Service, and Drugs."