Every finding on record at Home Hospice of Grayson County, Inc

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 medication review process includes the identification of the effectiveness of drug therapy, and drug side effects. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met, as evidenced by clinical record review and interview. 1 of 5 (20%) patients' comprehensive assessments revealed the hospice did not ensure the medication profiles were updated and drug regime reviews occurred when a new medication was added. Clinical Record 3: The start of care (SOC) was dated 08/29/2023, and the diagnosis was MALIGNANT NEOPLASM OF LEFT BREAST. The RN visit note dated 08/09/2023 documented the patient was using " 2 liters of oxygen. "The oxygen was not listed as part of the medication profile and was not part of the medications profile utilized for medication reconciliation. During a joint review of the clinical record and interview on 10/02/23, the Executive Director and the Intake coordinator confirmed that the drug profile was not updated to include oxygen.

It is required that the hospice provides an assessment of the patient’s and family’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) records reviewed, it was revealed that the agency did not ensure that an assessment of the patient's and family's spiritual needs was completed. CONTINUING PROR REQUIRED ACTION. Clinical Record 2: SOC 08/29/2023 diagnosis Alzheimer's chaplain documented a note on 9/5/2023 that stated she attempted to visit the patient, but no one came to the door, eight days after the patient elected hospice. As of 10/2/2023, there was no evidence that the spiritual assessment was completed. During an interview on 10/02/23, the Executive Director and Intake Coordinator confirmed that the initial spiritual assessment was not completed. CONTINUING PROR REQUIRED ACTION.

It is required that the hospice implements emergency preparedness (EP) policies and procedures. Informing local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency based on the patient’s medical or psychiatric condition, or home environment. The minimum information provided to facilitate patient evacuation and transportation including, if the patient is mobile or not, if the patient has life-dependent equipment, and if so, is it able to be transported (e.g., battery operated, size, condition, etc.), and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g., deaf, non-English speaking, etc.). A system of medical documentation that preserves patient information, protects the confidentiality of patient information, and secures and maintains the availability of records. This standard was not met as evidenced by clinical record review and interview. 19 of 19 (100%) clinical records reviewed, the agency did not ensure each hospice patient had a documented emergency plan based on the comprehensive assessment that would facilitate patient evacuation and transportation if needed. Clinical Record 2: The patient elected the hospice benefit on 2/26/2023, with a terminal diagnosis of Alzheimer’s disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 3: Clinical Record 3: The patient elected the hospice benefit on 4/19/2023, with a terminal diagnosis of heart disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 4: The patient elected the hospice benefit on 8/14/2023, with a terminal diagnosis of lung cancer. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 5: Clinical Record 5: The patient elected the hospice benefit on 1/14/2020, with a terminal diagnosis of chronic obstructive pulmonary disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 6: The patient elected the hospice benefit on 7/24/2023, with a terminal diagnosis of pancreatic cancer. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 7: The patient elected the hospice benefit on 4/6/2022, with a terminal diagnosis of alpha-1-antitrypsin deficiency with chronic obstructive pulmonary disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 8: The patient elected the hospice benefit on 5/18/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 9: The patient elected the hospice benefit on 5/25/2023, with a terminal diagnosis of cerebral vascular accident. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 10: The patient elected the hospice benefit on 2/2/2023, with a terminal diagnosis of cerebral vascular accident. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 11: The patient elected the hospice benefit on 4/24/2023, with a terminal diagnosis of Parkinson’s disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 12: The patient elected the hospice benefit on 9/22/2022, with a terminal diagnosis of cerebral vascular accident. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 13: The patient elected the hospice benefit on 3/30/2023, with a terminal diagnosis of heart failure. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 1: The patient elected the hospice benefit on 1/18/2023, with a terminal diagnosis of Alzheimer’s disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 14: The patient elected the hospice benefit on 6/2/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 15: The patient elected the hospice benefit on 11/21/2022, with a terminal diagnosis of multiple sclerosis. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 16: The patient elected the hospice benefit on 4/22/2023, with a terminal diagnosis of encephalopathy and cancer. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 17: The patient elected the hospice benefit on 8/18/2022, with a terminal diagnosis of cerebral vascular accident. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 18: The patient elected the hospice benefit on 2/8/2023, with a terminal diagnosis of heart failure. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. Clinical Record 19: The patient elected the hospice benefit on 8/11/2022, with a terminal diagnosis of Parkinson’s disease. There was no evidence in the clinical record that the hospice had developed a patient specific emergency plan based on the patient's comprehensive assessment to address the required information regarding the patient’s mobility, life-dependent equipment, and patient special needs, to quickly assist emergency communication and evacuation during a disaster. During a joint discussion with the hospice interdisciplinary team including the Executive Director/Administrator, Alternate Administrator, Interim Assistant Clinical Director, Hospice Physician, and the clinical and psychosocial staff during the Interdisciplinary Group Meeting on 8/23/2023, the team confirmed that there is no current process or procedure to address how to quickly access the required emergency assessment information for patient mobility, life-saving equipment, or any special needs such as cognitive disability, hearing or sight impairment, or language barrier in the event of a disaster. The entire team acknowledged that no current process was in place to provide an overview of these patient needs in an emergency.

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 intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's individualized written plan of care included interventions to manage the patient's symptoms. Clinical Record 7: The patient elected the hospice benefit on 4/6/2022, with a terminal diagnosis of alpha-1-antitrypsin deficiency with chronic obstructive pulmonary disease. The nurse documented on the recertification "Nurse Progress Note" dated 7/27/2023, in the cardiopulmonary section that the patient had dyspnea at rest and was on oxygen at 2 liters per minute (LPM) via nasal cannula (NC). Interdisciplinary Group (IDG) meetings dated 7/19/2023 and 8/22/2023 documented in the IDG updated plan of care “poor respiratory status related to emphysema, chronic obstructive pulmonary disease, and asthma. Oxygen was not included in the patient’s plan of care list of medications or treatments as of 8/23/2023. The plan of care did not include interventions for management of the patient’s cardiopulmonary symptoms including dyspnea and did not include interventions related to oxygen therapy. During an interview the Executive Director confirmed that the patient's plan of care did not include the oxygen or interventions related to management of the patient's dyspnea.

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. 18 of 19 (95%) clinical records reviewed, the agency did not ensure each patient's individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 1: The patient elected the hospice benefit on 1/18/2023, with a terminal diagnosis of Alzheimer’s disease. Review of a physician order dated 7/17/2023 revealed the physician had ordered 8 "as needed" (PRN) visits each for the nurse, the Social Worker, and the Volunteer to be included on the plan of care dated 7/17/23 to 9/14/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for volunteer services, only the PRN visit order. Clinical Record 2: The patient elected the hospice benefit on 2/26/2023, with a terminal diagnosis of Alzheimer’s disease. Review of a physician order dated 5/27/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, the Spiritual Counselor, and the Volunteer to be included on the plan of care dated 7/17/23 to 9/14/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for the spiritual counselor and volunteer services, only the PRN visits order. Clinical Record 3: The patient elected the hospice benefit on 4/19/2023, with a terminal diagnosis of heart disease. Review of a physician order dated 7/18/2023 revealed the physician had ordered 8 "as needed" (PRN) visits each for the nurse, the Social Worker, Spiritual Counselor, and the Volunteer to be included on the plan of care dated 7/18/23 to 10/15/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for volunteer services, only the PRN visit order. Clinical Record 4: The patient elected the hospice benefit on 8/14/2023, with a terminal diagnosis of lung cancer. Review of a physician order dated 8/14/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, the Spiritual Counselor, and the Volunteer to be included on the plan of care dated 8/14/23 to 11/11/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for volunteer services, only the PRN visits order. Clinical Record 5: The patient elected the hospice benefit on 1/14/2020, with a terminal diagnosis of chronic obstruction pulmonary disease. Review of a physician order dated 6/27/2023 revealed the physician had ordered 8 "as needed" (PRN) visits each for the nurse, the Social Worker, Spiritual Counselor, and the Volunteer to be included on the plan of care dated 6/27/23 to 8/25/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for volunteer services, only the PRN visit order. Clinical Record 6: The patient elected the hospice benefit on 7/24/2023, with a terminal diagnosis of pancreatic cancer. Review of a physician order dated 7/24/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, the Spiritual Counselor, and the Volunteer to be included on the plan of care dated 7/24/23 to 10/21/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for the spiritual counselor and volunteer services, only the PRN visits order. Clinical Record 7: The patient elected the hospice benefit on 4/6/2022, with a terminal diagnosis of alpha-1-antitrypsin deficiency with chronic obstructive pulmonary disease. Review of a physician order dated 7/30/2023 revealed the physician had ordered 8 "as needed" (PRN) visits each for the nurse, the Social Worker, Spiritual Counselor, and the Volunteer to be included on the plan of care dated 7/30/23 to 9/27/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for volunteer services, only the PRN visit order. Clinical Record 8: The patient elected the hospice benefit on 5/18/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. Review of a physician order dated 8/16/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, the Spiritual Counselor, and the Volunteer to be included on the plan of care dated 8/16/23 to 11/13/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for the spiritual counselor and volunteer services, only the PRN visits order. Clinical Record 10: The patient elected the hospice benefit on 2/2/2023, with a terminal diagnosis of cerebral vascular accident. Review of a physician order dated 8/1/2023 revealed the physician had ordered 8 "as needed" (PRN) visits each for the nurse, the Social Worker, Spiritual Counselor, and the Volunteer to be included on the plan of care dated 8/1/23 to 9/29/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for the spiritual counselor and volunteer services, only the PRN visits order. Clinical Record 11: The patient elected the hospice benefit on 4/24/2023, with a terminal diagnosis of Parkinson’s disease. Review of a physician order dated 7/23/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, the Spiritual Counselor, and the Volunteer to be included on the plan of care dated 7/23/23 to 10/20/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for volunteer services, only the PRN visit order. Clinical Record 12: The patient elected the hospice benefit on 9/22/2022, with a terminal diagnosis of cerebral vascular accident. Review of a physician order dated 7/19/2023 revealed the physician had ordered 8 "as needed" (PRN) visits each for the nurse, the Social Worker, Spiritual Counselor, and the Volunteer to be included on the plan of care dated 7/19/23 to 9/16/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for volunteer services, only the PRN visit order. Clinical Record 13: The patient elected the hospice benefit on 3/30/2023, with a terminal diagnosis of heart failure. Review of a physician order dated 6/28/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, the Spiritual Counselor, and the Volunteer to be included on the plan of care dated 6/28/23 to 9/25/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. Clinical Record 14: The patient elected the hospice benefit on 6/2/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. Review of a physician order dated 6/2/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, the Spiritual Counselor, and the Volunteer to be included on the plan of care dated 6/2/23 to 8/30/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for volunteer services, only the PRN visit order. Clinical Record 15: The patient elected the hospice benefit on 11/21/2022, with a terminal diagnosis of multiple sclerosis. Review of a physician order dated 2/19/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, and the Spiritual Counselor to be included on the plan of care dated 2/19/23 to 5/19/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. Clinical Record 16: The patient elected the hospice benefit on 4/22/2023, with a terminal diagnosis of encephalopathy and cancer. Review of a physician order dated 4/22/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, and the Spiritual Counselor to be included on the plan of care dated 4/22/23 to 7/30/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. The plan of care did not include a frequency of visits for spiritual counselor, only the PRN visit order. Clinical Record 17: The patient elected the hospice benefit on 8/18/2022, with a terminal diagnosis of cerebral vascular accident. Review of a physician order dated 4/15/2023 revealed the physician had ordered 8 "as needed" (PRN) visits each for the nurse, the Social Worker, and Spiritual Counselor to be included on the plan of care dated 4/15/23 to 6/13/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. Clinical Record 18: The patient elected the hospice benefit on 2/8/2023, with a terminal diagnosis of heart failure. Review of a physician order dated 5/9/2023 revealed the physician had ordered 12 "as needed" (PRN) orders each for the nurse, the Social Worker, and the Spiritual Counselor to be included on the plan of care dated 5/9/23 to 8/6/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. Clinical Record 19: The patient elected the hospice benefit on 8/11/2022, with a terminal diagnosis of Parkinson’s disease. Review of a physician order dated 4/4/2023 revealed the physician had ordered 8 "as needed" (PRN) visits each for the nurse, the Social Worker, and Spiritual Counselor to be included on the plan of care dated 4/4/23 to 6/2/23. The orders did not include qualifying statements or documented reasons for these PRN visits to be provided to the patient. During a joint discussion with the Interdisciplinary Group (IDG) on 8/23/2023, including the hospice Executive Director/Administrator, Alternate Administrator, Interim Assistant Clinical Director, Hospice Physician, and the clinical and psychosocial staff, the group confirmed current practice is that every patient in every discipline is currently given 12 PRNs for a certification period. The IDG agreed the plans of care were not individualized to meet the patient and family needs and the assessment for the need for PRN orders should be on a case-by-case basis as well as discipline-specific.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. 1 of 12 (8%) clinical records reviewed with spiritual counseling services were accepted, the agency did not ensure spiritual counselor visits followed the frequency ordered in the Plan of Care. Clinical Record 9: The patient elected the hospice benefit on 5/25/2023, with a terminal diagnosis of cerebral vascular accident. A physician order dated 6/1/2023 ordered the spiritual counselor to provide visits at a frequency of one visit every five weeks beginning on 6/1/2023. There was no documented evidence in the clinical record that the Spiritual Counselor provided a visit for the month of June. The Spiritual Counselor documented a note dated 6/1/2023, that stated attempts had been made to reach the family to schedule a visit, but other attempts to reach the family were documented and the record contained no documentation of missed visits. During an interview on 8/23/2023, the Executive Director and the Clinical Supervisor/Nurse Practitioner confirmed there was a missing spiritual counselor visit in the clinical record.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. 3 of 15 (20%) clinical records reviewed with Hospice Aide services, the agency did not ensure the Hospice Aide reported changes to the Registered Nurse that related to the plan of care. Clinical Record 2: The patient elected the hospice benefit on 2/26/2023, with a terminal diagnosis of Alzheimer’s disease. The hospice aide care plan assigned the aide to provide oral care, hair care, shave, tidy the bathroom and feeding assistance. The aide documented on visit notes dated 7/24/2023, 8/7/2023 and 8/11/2023 that the patient /caregiver had refused oral care, hair care, shave, tidy the bathroom and feeding assistance at each visit. There was no documented evidence in the clinical record that the Aide had notified the Registered Nurse of the patient/caregiver refusal of aide interventions for these visits. Clinical Record 4: The patient elected the hospice benefit on 8/14/2023, with a terminal diagnosis of lung cancer. The hospice aide care plan assigned the aide to provide bath, toilet, peri care, hair care, skin care, tidy patient area, tidy bathroom, laundry, and change linen. The aide documented on visit notes dated 8/16/2023 and 8/18/2023 that the patient /caregiver had refused bath, peri care, toilet, hair care, skin care, tidy patient area, tidy bathroom, laundry, and change linen. The aide documented on the aide visit note dated 8/17/2023 that the patient/caregiver refused toilet, hair care, tidy bathroom, laundry, and change linen. There was no documented evidence in the clinical record that the Aide had notified the Registered Nurse of the patient/caregiver refusal of aide interventions for these visits. Clinical Record 10: The patient elected the hospice benefit on 2/2/2023, with a terminal diagnosis of cerebral vascular accident. The hospice aide care plan assigned the aide to provide bath, peri care, toilet, oral care, hair care, skin care, tidy patient area, change linen, and provide companionship. The aide documented on the visit note dated 8/1/2023 that the patient /caregiver refused bath, peri care, toilet, oral care, hair care, skin care, tidy patient area, change linen, and provide companionship. There was no documented evidence in the clinical record that the Aide had notified the Registered Nurse of the patient/caregiver refusal of aide interventions for the visit. During a joint discussion with the hospice Executive Director/Administrator, Alternate Administrator, Interim Assistant Clinical Director, Hospice Physician, and field nurses during the Interdisciplinary Group Meeting on 8/23/2023, it was confirmed that there is no current practice or process for the Hospice Aide to communicate any deviation from the Hospice Aide Care Plan written by the RN.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 4 (50%) clinical records reviewed with Volunteer services, revealed the agency did not ensure that volunteers were available to provide direct care when requested by the patient or caregiver. Clinical Record 4: The patient elected the hospice benefit on 8/14/2023, with a terminal diagnosis of lung cancer. The "IDT [interdisciplinary team] Request for Volunteer Needs Assessment" form was completed by the Medical Social Worker (MSW) on 8/14/2023. The MSW and noted that the patient/family requested a volunteer for socialization and support. Review of the Nurse Progress Initial Assessment dated 8/14/2023, under "Patient/Family Discussion" and "Following services accepted," the nurse documented that volunteer services were requested and accepted. The Social Worker Progress Note Comprehensive Assessment dated 8/15/2023 included documentation that stated in part, "Family wants... volunteers for socialization and support believing it would be good for patient." The Interdisciplinary Note dated 8/18/2023 completed by the Volunteer Coordinator (VC) stated in part, "VC received IDT request for socialization and presence. VC contacted caregiver/sister on this day to discuss volunteer needs at this time. [Sister] explained between herself and her two other siblings they alternate between caregiving and checking on the patient during the day. [Sister] is undergoing chemo and will be out several days in a row leaving them with a need for continued care while she is gone. [Sister] stated the patient is up for only a few hours a day due to the pain she experiences. She expressed reaching out to friends at church to ask if they could provide this help ongoing. VC verbalized there is no volunteer available at this time to support their volunteer needs but that notes have been made and when a volunteer is available, she would be contacted immediately." Clinical Record 11: The patient elected the hospice benefit on 4/24/2023, with a terminal diagnosis of Parkinson’s disease. A request for a volunteer was documented on the IDT Request for Volunteer form completed by the nurse and dated 4/24/2023 for "caregiver respite and socialization and support". The VC documented on the interdisciplinary note dated 4/24/2023, "Received request for socialization & presence as well as possible caregiver respite from MSW on 4/24/2023. Volunteer not available at this time." During an interview on 8/23/2023, the Volunteer Coordinator confirmed that there was no process currently in place to ensure that volunteer services could be provided when requested by the patient/family. She stated she actively trying to recruit more volunteers for the program to be able to provide volunteer services.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s: overall management and operation, and provision of care and services. THIS IS A CMS CONDITION LEVECONDITION DEFICIENCY This CONDITION was not met as evidenced by clinical record review, personnel record review, document review, and interview. The organization failed as follows: to ensure all employees had a documented competency assessment each year per agency policy; 7% noncompliance [HSRM.14.I/L663]; to ensure the patient's Recertification of Terminal Illness was completed no later than two days after the beginning of the next benefit period, 43% noncompliance [HCPC.6.I/L676]; to ensure each hospice patient had a documented emergency plan based on the comprehensive assessment that would facilitate patient evacuation and transportation if needed, 100% noncompliance [HSEP.3.D/E19]; to ensure each patient's individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs; to ensure that each patient's individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs, 95% noncompliance [HCPC.21.I/L547]; to ensure that spiritual counselor visits followed the frequency ordered in the Plan of Care, 6% noncompliance [HDT.11.I/L598]; to ensure that volunteers were available to provide direct care when requested by the patient or caregiver, 50% noncompliance [HCDT.21.I/L644]. The cumulative effective of these systemic issues calls into question the ability of the hospice agency to provide quality care and services in a safe environment.

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. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. 1 of 14 (7%) personnel records reviewed, the agency did not ensure all employees had a documented competency assessment each year per agency policy. Agency policy Performance Appraisals 6.230, stated in part, all employees shall have a performance appraisal annually, after the appraisal has been completed, the signed form should be filed in the employee's personnel file. Agency policy Competency of Clinical Staff (no number) Effective date 2/20/2002, stated in part, Clinical competency evaluations are performed annually to assess the basic skills for all staff who provide patient/family care. Agency policy Competency Assessment and Development 2.210, stated in part, Annual critical competencies will be assessed through supervisory visits, written testing, case reviews. An annual record of each employee's competency evaluation will be retained in the employee's human resources file. Personnel Record 14: The Spiritual Care Counselor with the date of hire of 10/31/2016 did not have a Hospice Spiritual Counselor Competency Assessment evaluation documented for 2021 in the personnel file. During an interview and joint personnel record review on 8/24/2023, the Executive Director confirmed that while she was certain the annual competency for 2021 had been performed, it was missing from the personnel file.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: The primary terminal condition; Related diagnosis(es), if any; Current subjective and objective medical findings; Current medication and treatment orders; and Information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review, document review and interview. 4 of 19 (21%) clinical records reviewed, the agency did not ensure that each hospice patient had a documented initial certification of terminal illness completed per agency policy. Agency policy Medical Supervision (4.300) stated in part, "The Attending Physician and Medical Director are responsible for the initial certification of terminal illness, verbally within 48 hours of admission and in writing within 14 calendar days of admission." Clinical Record 6: The patient elected the hospice benefit on 7/24/2023, with a terminal diagnosis of pancreatic cancer. The clinical record included a verbal certification of terminal illness dated 7/24/203. There is no documented evidence in the clinical record that a written certification of terminal illness (CTI) was completed for the benefit period dated 7/24/2023 to 10/21/2023, as of the date of record review on 8/24/2023. Clinical Record 8: The patient elected the hospice benefit on 5/18/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The clinical record included a verbal certification of terminal illness dated 5/18/203. There is no documented evidence in the clinical record that a written CTI was completed for the benefit period dated 5/18/2023 to 8/15/2023, as of the date of record review on 8/24/2023. Clinical Record 9: The patient elected the hospice benefit on 5/25/2023, with a terminal diagnosis of cerebral vascular accident. The clinical record included a verbal certification of terminal illness dated 5/25/203. There is no documented evidence in the clinical record that a written CTI was completed for the benefit period dated 5/25/2023 to 8/22/2023, as of the date of record review on 8/24/2023. Clinical Record 14: The patient elected the hospice benefit on 6/2/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The clinical record included a verbal certification of terminal illness dated 6/2/203. There is no documented evidence in the clinical record that a written CTI was completed for the benefit period dated 6/2/2023 to 8/30/2023, as of the date of record review on 8/24/2023. During an interview on 8/24/2023, the Executive Director confirmed that the Medical Director was behind in his documentation, and she was aware.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. 6 of 14 (43%) clinical records reviewed in which the patient was recertified for hospice services, the agency did not ensure the patient's Recertification of Terminal Illness was completed no later than two days after the beginning of the next benefit period. Clinical Record 5: The patient elected the hospice benefit on 1/14/2020, with a terminal diagnosis of chronic obstruction pulmonary disease. There was no documented evidence in the clinical record that a written recertification of terminal illness was completed by the physician for benefit periods dated 4/28/2023 to 6/26/2023 and 6/27/2023 to 8/25/2023. Clinical Record 7: The patient elected the hospice benefit on 4/6/2022, with a terminal diagnosis of alpha-1-antitrypsin deficiency with chronic obstructive pulmonary disease. There was no documented evidence in the clinical record that a written recertification of terminal illness was completed by the physician for the benefit period dated 7/30/2023 - 9/27/2023. Clinical Record 8: The patient elected the hospice benefit on 5/18/2023, with a terminal diagnosis of alpha-1-antitrypsin deficiency with chronic obstructive pulmonary disease. There was no documented evidence in the clinical record that a written recertification of terminal illness was completed by the physician for the benefit period dated 8/16/2023 - 11/13/2023. Clinical Record 12: The patient elected the hospice benefit on 9/22/2022, with a terminal diagnosis of cerebral vascular accident. There was no documented evidence in the clinical record that a written recertification of terminal illness was completed by the physician for the benefit periods dated 5/18/2023 to 7/18/2023 and 7/19/2023 to 9/16/2023. Clinical Record 17: The patient elected the hospice benefit on 8/18/2022, with a terminal diagnosis of cerebral vascular accident. The recertification of terminal illness notes were completed and signed by the physician on 6/29/2023 for the benefit periods dated 2/14/2023 to 4/14/2023 and 4/15/2023 to 6/13/2023. The recertification of terminal illness notes were not completed per agency policy and regulatory requirement. Clinical Record 19: The patient elected the hospice benefit on 8/11/2022, with a terminal diagnosis of Parkinson’s disease. Both recertification of terminal illness forms were completed and signed by the physician on 6/8/2023 for the benefit periods dated 2/3/2023 to 4/3/2023 and 4/4/2023 to 6/2/2023. The recertification of terminal illness forms were not completed per agency policy and regulatory requirement. During an interview dated 8/24/2023, the Executive Director confirmed that the Medical Director was behind in his documentation.

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, and 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 2 (50%) clinical records reviewed of patients that were discharged from the agency, the hospice did not ensure the patient's discharge summary contained the required information to facilitate coordination of care. Clinical Record 18: The patient elected the hospice benefit on 2/8/2023, with a terminal diagnosis of heart failure. The patient was transferred to another hospice agency on 5/18/2023. The Discharge Summary dated 5/17/2023 included documentation of the reason the patient was being discharged from the agency and included documentation that the nurse had notified the patient/caregiver, the hospice physician, the pharmacy, the equipment company, and the receiving hospice’s administrative personnel. The nurse also documented a note that stated, "Notified accepting agency of transfer information." A fax cover sheet dated 5/25/2023 revealed the discharge summary sent to the receiving hospice agency include 2 Physician Certifications of Terminal Illness for the benefit periods 2/8/23 to 5/8/23 and 5/9/23 to 8/6/23 and no other information. There was no documented evidence in the clinical record, that the patient's plan of care, medication list, and latest physician orders had been sent to the receiving hospice agency. The discharge summary did not include a summary of the patient's hospice stay, the latest plan of care, a list of medications, treatments, or any symptom management issues to assist with continuity of care for the patient during the transfer. In an interview and joint record review with the Executive Director and the office nurse on 8/24/2023, it was confirmed that the patient's Discharge Summary did not contain the required information nor was there any other documentation in the clinical record that the patient's plan of care, medication list, or physician orders were sent to the receiving agency.

It is required that the designated IDG (Interdisciplinary Group) member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, physician certification and recertification of the terminal illness. This standard was not met as evidenced by interview and observation. 1 of 1 (100%) home visit observations where the patient resided in a Skilled Nursing Facility (SNF), the hospice did not ensure physician certification and recertification of terminal illness was provided to the facility. Home Visit 1: During the home visit observation, a review of the facility chart revealed the initial physician certification of terminal illness for the benefit period from 1/18/2023 to 4/17/2023 was provided to the facility. The facility chart did not include the physician certification of terminal illness for the second benefit period dated 4/18/2023 to 7/16/2023 and the third benefit period dated 7/17/2023 to 9/14/2023. The hospice had not provided the facility with copies of the physician’s certification of terminal illness for the second and third benefit periods. During a joint review of the facility chart with the Registered Nurse (RN), the RN confirmed that the physician's certifications for the patient's second and third benefit periods were not in the facility chart.