Every finding on record at Home Hospice of Odessa/Midland, LLC

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 20 (5%) clinical records reviewed revealed the agency did not ensure that every patient received an initial bereavement risk assessment as part of the initial comprehensive assessment. CLINICAL RECORD 12: The patient, who resided at a nursing facility, elected the hospice benefit on 09/24/2024 with the diagnosis of Huntington's Disease. At admission, the patient declined social work and chaplain services, so no initial psychosocial assessments were completed. The initial Registered Nurse Assessment documented 09/24/2024 did not include an initial bereavement risk assessment despite noting that "... All information gathered from nurse and family …" No bereavement assessment risk was noted during the Interdisciplinary Group Meeting on 10/03/2024. During a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 2) on 02/06/2024, she confirmed that the patient did not have an initial bereavement risk assessment documented.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 20 (5%) clinical records reviewed revealed the agency did not ensure that the patient's identified problems and planned interventions were updated to include dysphagia and the related risk of aspiration. CLINICAL RECORD 11: The patient, who resided at home, elected the hospice benefit on 09/28/2024 with the diagnosis of unspecified heart disease with the comorbid condition of chronic obstructive pulmonary disease. The plans of care for the benefit periods 09/28/2024 to 12/26/2024 and 12/27/2024 to 03/26/2025 were reviewed. During an on-call visit by the Registered Nurse (RN) on 01/30/2025, the RN documented that the patient was minimally responsive during the visit, and the daughter reported that she had provided the patient eggs through a syringe that morning, but he had to spit them out. Education was provided to the daughter regarding the need to stop forcing food and only give the patient food or drinks if he requested them. Additionally, the nurse noted that she provided mouth swabs and explained that the patient should use the swabs if he wants water to ensure that he does not aspirate. The nurse received an order to discontinue oral tablet/capsule medications. The plan of care did not include any identified problems with planned interventions related to the patient's risk for aspiration, the patient's family's need for education related to end-of-life feeding needs, and safety. During a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 2) on 02/07/2025, it was confirmed that the patient's aspiration risk and the family's need for training on feeding at the end of life were not identified by any problems or interventions documented in the patient's plan of care.

It is required that each patient’s individualized written plan of care includes 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 20 of 20 (100%) clinical records reviewed revealed the agency did not ensure that the patient's plans of care identified specific, measurable goals that reflected the patient and family goals. CLINICAL RECORD 1: The patient, who resided in an assisted living facility, elected the hospice benefit on 09/10/2024 with the diagnosis of Alzheimer's disease. The plans of care for the benefit periods 09/10/2024 to 12/08/2024 and 12/09/2024 to 03/08/2025 were reviewed. The plans of care included the following non-specific, unmeasurable goals: adequate nutrition would be maintained as long as possible, nutritional needs would be met, patient/family/caregivers would be able to verbalize and demonstrate an understanding of the disease's impact on nutrition, the patient would maintain the maximum mobility function, patient/caregiver would be able to verbalize an understanding of the use of durable medical equipment (DME) for maximum mobility functions, the patient would function at the maximum cognitive level, would have minimal episodes of agitation, the patient would remain free from harm, to establish a calm reassuring environment, the patient would communicate needs in a manner that is understood by the patient's caregiver, that the family/caregivers would be referred to appropriate counseling options if assessed at a moderate or high risk for bereavement, the family/caregiver will grieve appropriately, the patient would experience spiritual comfort, the patient/family would utilize spiritual resources, and the patient/family would receive spiritual support. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 2: The patient, who resided at home, elected the hospice benefit on 10/05/2024 with the diagnosis of neurocognitive disorder with Lewy Bodies. The plans of care for the benefit periods 09/29/2024 to 11/27/2024 and 11/28/2024 to 01/26/2025 were reviewed. The plans of care included the following non-specific, unmeasurable goals: the patient/family/caregivers would be able to identify and verbalize signs and symptoms of anxiety medications, nutritional needs would be met, the patient would maintain adequate nutrition as long as possible, the patient would be able to identify and avoid specific factors that exacerbate episodes of dyspnea, the patient would be able to breathe comfortably, the patient would function at the maximum cognitive level, remain free from harm, and the patient would have minimal episodes of agitation, the patient/caregiver would be able to verbalize an understanding of the use of the durable medical equipment for maximum mobility function, would maintain maximum mobility functions, that he patient would remain at an acceptable level of pain, the patient/caregiver would be able to verbalize an understanding of medications, the patient/family/caregiver would prepare end of life arrangements, the family/caregiver would understand the signs of dying, the patient/family would receive spiritual support, would utilize spiritual resources, and experience spiritual comfort. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 3: The patient, who resided at home, elected the hospice benefit on 12/19/2024 with the diagnosis of unspecified lump in the left breast. The plan of care for the benefit period 12/19/2024 to 03/18/2025 was reviewed. The plan of care included the following non-specific, unmeasurable goals: the patient would remain free from constipation and/or bowel impaction, the patient would assist in self-care as capable, to remain safe during the completion of activities of daily living, to maintain skin integrity, the patient/caregiver could verbalize methods of maintaining skin integrity and signs and symptoms of skin breakdown, the patient would remain at an acceptable level of pain, the patient/caregiver would verbalize an understanding of medications, the family/caregiver will be referred to appropriate counseling if assessed at moderate or high risk for bereavement, the family/caregiver will grieve appropriately, the patient would experience spiritual comfort, the patient/family would utilize spiritual resources, and the patient/family would receive spiritual support. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 4: The patient, who resided at home, elected the hospice benefit on 07/25/2023 with the diagnosis of unspecified cirrhosis of the liver. The plans of care for the benefit periods 10/25/2024 to 12/23/2024 and 12/24/2024 to 02/21/2025 were reviewed. The plans of care included the following non-specific, unmeasurable goals: that the patient would maintain adequate nutrition for as long as possible, that the patient's nutritional needs would be met, and to maintain comfort and oral hygiene, to remain free from skin breakdown, remain free of urinary tract infections, that the patient/family would be aware of the signs of impending death, for the nurse to anticipate the physical changes as the disease progressed, for the patient/family to understand hospice services, maintain maximum mobility functions, patient/family to verbalize an understanding of the use of durable medical equipment for maximum mobility, decreased edema, patient/family would verbalize an understanding of the signs of increased fluid retention, the family/caregiver will be referred to appropriate counseling if assessed at a moderate or high risk for bereavement, the family/caregiver will grieve appropriately, the patient would experience spiritual comfort, the patient/family would utilize spiritual resources, and the patient/family would receive spiritual support. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 5: The patient, who resided at home, elected the hospice benefit on 10/09/2024 with the diagnosis of unspecified heart failure. The plans of care for the benefit periods 10/09/2024 to 01/06/2025 and 01/07/025 to 04/06/2025 were reviewed. The plans of care included the following non-specific, unmeasurable goals: the patient would remain at an acceptable level of pain, remain free from urinary tract infections, the patient/family would verbalize and demonstrate an understanding of the impact of the disease process on nutrition, and the patient would discuss their personal response to dying. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 6: The patient, who resided at home, elected the hospice benefit on 11/12/2024 with the diagnosis of Parkinson's disease. The plans of care for the benefit period 11/12/2024 to 02/09/2025 was reviewed. The plan of care included the following non-specific, unmeasurable goals: to maintain adequate nutrition as long as possible, that medications would be effective for symptom management, have lessened signs and symptoms of anxiety/agitation, for medications to be effective for constipation, remain free from constipation/impaction, maintain patent airway and clear lung sounds, be able to breathe comfortably, to identify and avoid specific factors that exacerbate episodes of dyspnea, family/caregiver to understand the signs of dying, prepare end of life arrangements, and experience spiritual comfort. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 7: The patient, who resided at home, elected the hospice benefit on 12/05/2024 with the diagnosis of intrahepatic bile duct carcinoma. The plan of care for the benefit period 12/05/2024 to 03/04/2025 was reviewed. The plan of care included the following non-specific, unmeasurable goals: remain safe during completion of activities of daily living, have decreased edema, verbalize an understanding of the signs of increased fluid retention, be able to breathe comfortably, that the patient would be able to identify and avoid specific factors that exacerbate episodes of dyspnea, maintain maximum mobility, remain at an acceptable level of pain, understand signs of dying, prepare end of life arrangements, the patient would experience spiritual comfort, and the patient/family would receive spiritual support. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 8: The patient, who resided in a nursing facility, elected the hospice benefit on 02/13/2023 with the diagnosis of moderate protein-calorie malnutrition. The plans of care for the benefit periods 10/05/2024 to 12/03/2024 and 12/04/2024 to 02/01/2025 were reviewed. The plan of care included the following non-specific, unmeasurable goals: the patient will be allowed to refuse foods/fluids, will be in control of when to eat and how much to eat, remain comfortable, will verbalize an understanding of decreased appetite in the terminal patient, remain at an acceptable pain level, verbalize an understanding of pain medications, understand signs of dying, prepare end of life arrangements, verbalize feelings, assisted with the grief process, deal with losses and/or life changes. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 9: The patient, who resided at home, elected the hospice benefit on 04/05/2024 with the diagnosis of chronic obstructive pulmonary disease. The plans of care for the benefit periods 12/01/2024 to 01/29/2025 and 01/30/2025 to 03/30/2025 were reviewed. The plan of care included the following non-specific, unmeasurable goals: maintain adequate nutrition as long as possible, nutritional needs will be met, verbalize/demonstrate an understanding of the impact of the disease on nutritional status, identify specific stressors/factors that exacerbate episodes of shortness of breath, will report improved breathing, decreased edema, verbalize an understanding of the signs of increased fluid retention, remain at an acceptable level of pain, verbalize an understanding of pain medications, maintain maximum mobility, verbalize an understanding of the use of durable medical equipment (DME) for maximum mobility, the family/caregiver will be referred to appropriate counseling options if assessed at moderate or high bereavement risk, family/caregiver will grieve appropriately, receive spiritual support, utilize spiritual resources, and experience spiritual comfort. There was no documented evidence that included measurable goals. CLINICAL RECORD 10: The patient, who resided at home, elected the hospice benefit on 08/02/2024 with the diagnosis of malignant neoplasm of the posterior wall of the bladder. The plans of care for the benefit periods 10/31/2024 to 01/28/2025 and 01/29/2025 to 03/29/2025 were reviewed. The plan of care included the following non-specific, unmeasurable goals: medications effective for constipation, free from constipation or fecal impaction, resolution of deep vein thrombosis (DVT), reduction of DVT pain, remain at an acceptable level of pain, understand pain medications, remain free from skin breakdown, verbalize feelings, and be assisted with the grief process. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 11: The patient, who resided at home, elected the hospice benefit on 09/28/2024 with the diagnosis of unspecified heart disease with the comorbid condition of chronic obstructive pulmonary disease. The plans of care for the benefit periods 09/28/2024 to 12/26/2024 and 12/27/2024 to 03/26/2025 was reviewed. The plan of care included the following non-specific, unmeasurable goals: report improved breathing, identify specific factors that exacerbate episodes of shortness of breath, comfort and symptom control related to cardiac status, compliance with medication regimen, breathe comfortably, remain free from urinary tract infections, remain at an acceptable level of pain, acknowledge use of comfort medications, verbalize feeling, and be assisted with the grief process There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 12: The patient, who resided at a nursing facility, elected the hospice benefit on 09/24/2024. The plans of care for the benefit periods 09/24/2024 to 12/22/2024 and 12/23/2024 to 03/22/2025 were reviewed. The plan of care included the following non-specific, unmeasurable goals: fall risk to be addressed, remaining free from injury, maintaining adequate nutrition as long as possible, nutritional needs to be met, anxiety medications effective for symptom management, medications effective for constipation, remain free from constipation and fecal impaction, will be assisted with the completion of activities of daily living (ADLs), stay safe during the completion of ADLs. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 13: The patient, who resided at home, elected the hospice benefit on 01/02/2024 with the diagnosis of alcoholic cirrhosis of the liver. The plan of care for the benefit periods 10/28/2024 to 12/16/2024 and 12/27/2024 to 02/24/2025 were reviewed. The plan of care included the following non-specific, unmeasurable goals: maintain adequate nutrition as long as possible, maintain oral comfort and hygiene, nutritional needs to be met, verbalize/demonstrate and understanding of the impact of the disease on nutrition, medications effective for constipation, remain free from constipation or fecal impaction, be assisted with completion of activities of daily living (ADLs), remain safe during completion of ADLs, be aware of the signs of impending death, understand hospice services, nurse to anticipate physical changes as the disease progresses, understand signs of dying, prepare end of life arrangements, family/caregiver to be referred to appropriate counseling options if assessed at moderate or high bereavement risk, grieve appropriately, utilize spiritual resources, receive spiritual support, and experience spiritual comfort. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 14: The patient, who resided at home, elected the hospice benefit on 03/27/2023 with the diagnosis of Alzheimer's disease. The plans of care for the benefit periods 11/06/2024 to 01/04/2025 and 01/05/2025 to 03/05/2025 were reviewed. The plan of care included the following non-specific, unmeasurable goals: verbalize/demonstrate an understanding of the impact of the disease process on nutrition, nutritional needs met, maintain adequate nutrition as long as possible, maintain oral hygiene and comfort, family will identify and verbalize signs and symptoms of anxiety/agitation, will have lessened signs and symptoms of anxiety/agitation, anxiety medication effective for symptom management, maintain skin integrity, maintain dignity related to bowel incontinence, remain free from urinary tract infections, remain safe during completion of activities of daily living (ADLs), acknowledge use of comfort medications, stay at an acceptable pain level, referred to appropriate counseling if assessed at moderate or high bereavement risk, prepare end of life arrangements, understand signs of dying, receive spiritual support, utilize spiritual resources, and experience spiritual comfort. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 15: The patient, who resided at home, elected the hospice benefit on 07/16/2024 with the diagnosis of malignant neoplasm of the liver. The patient revoked hospice services on 10/25/2024. The plans of care for the benefit periods 07/16/2024 to 10/13/2024 and 10/14/2024 to 02/11/2025 were reviewed. The plan of care included the following non-specific, unmeasurable goals: caregiver to demonstrate appropriate ability to use durable medical equipment (DME), caregiver to verbalize and/or demonstrate an understanding of the impact of the disease on the musculoskeletal system, fall risk will be addressed, report falls to hospice, provide patient with frequent reminders to use walker/wheelchair, maintain musculoskeletal status as long as possible, remain free from injury, maintain adequate nutrition as long as possible, maintain oral comfort and hygiene, verbalize impact of disease on nutritional status, remain free from depression, have sufficient understanding of the end of life process, verbalize an understanding of the role of hospice in patient care, remain at an acceptable level of pain, verbalize an understanding of medications, verbalize an understanding of the disease process, the caregiver would have positive interactions with the patient, understand sings of dying, prepare end of life arrangements, verbalize grief feelings, be assisted with the grief process, resolves or decreases spiritual conflicts, receive spiritual support, and experience spiritual comfort. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 16: The patient, who resided at home, elected the hospice benefit on 06/17/2024 with the diagnosis of a nonspecific abnormal finding of the lung field. He was discharged from hospice services on 09/05/2024 for an (extended prognosis). The plan of care for the benefit period 06/17/2024 to 09/14/2024 was reviewed. The plan of care included the following non-specific, unmeasurable goals: identify specific stressors/factors that exacerbate episodes of ineffective breathing, be able to breathe comfortably, remain at an acceptable level of pain, verbalize an understanding of medications, medications would be effective for constipation, verbalize feelings, be assisted with the grief process. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 17: The patient, who resided in a nursing facility, elected the hospice benefit on 02/01/2024 with the diagnosis of senile degeneration of the brain. She died while on hospice services on 07/05/2024. The plan of care for the benefit period 05/01/2024 to 07/29/2024 was reviewed. The plan of care included the following non-specific, unmeasurable goals: caregiver to demonstrate appropriate ability to use durable medical equipment, fall risk addressed, report falls to hospice, maintain dignity related to bowel incontinence, decreased edema, remain free from skin breakdown, be provided with frequent toileting and/or brief changes, assist in self-care as able, be assisted with the completion of activities of daily living, verbalize methods of maintaining skin integrity, verbalize signs and symptoms of skin breakdown, family/caregiver understands signs of dying, prepare end of life arrangements, experience spiritual comfort. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 18: The patient, who resided at home, elected the hospice benefit on 06/15/2024 with the diagnosis of malignant neoplasm of the pancreas. He died while on hospice services on 07/26/2024. The plan of care for the benefit period 06/15/2024 to 09/12/2024 was reviewed. The plan of care included the following non-specific, unmeasurable goals: maintain adequate nutrition as long as possible, maintain oral comfort/hygiene, medications effective for symptom management, identify and verbalize signs and symptoms of anxiety, maintain maximum mobility, patient/caregiver be able to verbalize an understanding of the use of durable medical equipment for maximum mobility, remain at an acceptable level of pain, verbalize an understanding of medications, have coping mechanisms in place, identify support systems available to them. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 19: The patient, who resided in a nursing facility, elected the hospice benefit on 05/30/2024 with the diagnosis of senile degeneration of the brain. She died while on hospice services on 08/18/2024. The plans of care for the benefit periods 05/30/2024 to 07/28/2024 and 07/29/2024 to 09/26/2024 were reviewed. The plan of care included the following non-specific, unmeasurable goals: patient/caregiver would be able to cope with communication barriers, that the caregiver would demonstrate appropriate ability to use durable medical equipment (DME), report falls to hospice, remain free from injury, maintain adequate nutrition as long as possible, maintain oral comfort/hygiene, patient/family/caregiver would verbalize and/or demonstrate an understanding of the impact of the disease process on nutrition, medications effective for constipation, remain free from constipation or fecal impaction, report to nursing facility if no bowel movement in three to five days, maintain dignity related to bowel incontinence, maintain skin integrity, verbalize an understanding of the signs of increased fluid retention, express thoughts and feelings, patient would be provided with frequent toileting and/or brief changes, remain free from skin breakdown, remain free from urinary tract infections, maintain maximum mobility, verbalize an understanding of the use of DME to maintain maximum mobility, remain safe during completion of activities of daily living (ADLs), patient would be assisted with completion of ADLs, function at maximum cognitive level, remain free from harm, participate in ADLs at the maximum of functional ability, caregiver would demonstrate the ability to cope with the patient's behavior and mental status, maintained in a safe environment, and needs will be communicated by various means and/or modalities. There was no documented evidence that the patient's plan of care included measurable goals of care. CLINICAL RECORD 20: The patient, who resided at home, elected the hospice benefit on 12/06/2024 with the diagnosis of senile degeneration of the brain. She revoked the hospice benefit on 12/15/2024. The plan of care for the benefit period 12/06/2024 to 03/05/2025 was reviewed. The plan of care included the following non-specific, unmeasurable goals: maintain adequate nutrition as long as possible, maintain oral comfort and hygiene, verbalize an understanding of the impact of the disease process on nutritional status, demonstrate an understanding even if not able to speak, use alternate methods of communication effectively, maintain patent airway and clear lung sounds, remain free from aspiration pneumonia, remain free from urinary tract infections, remain free from skin breakdown r/t incontinence, assisted with completion of activities of daily living (ADLs) by family, remain safe during completion of ADLs, have minimal episodes of agitation, remain free from harm, verbalize feelings, be assisted with the grief process, deal with losses/life changes, understand the grieving process, understands signs of dying, prepare end of life arrangements, utilize spiritual resources, receive spiritual support, and experience spiritual comfort. There was no documented evidence that the patient's plan of care included measurable goals of care. During a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 2) on 02/06/2025, the identified goals in the patients' plans of care do not identify patient-specific goals, nor are the goals measurable.

It is required that each patient’s individualized written plan of care reflects patient and family goals. It includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 20 (5%) clinical records reviewed revealed the agency did not ensure that the patient's plan of care included all treatments necessary to meet the needs of the patient. CLINICAL RECORD 5: The patient, who resided at home, elected the hospice benefit on 10/09/2024 with the diagnosis of unspecified heart failure. A review of the initial Registered Nurse (RN) visit on 10/09/2024, the nurse documented a deep tissue injury (DTI) with eschar to the fifth left toe and a DTI to the first left toe. The right heel was also noted to have a DTI. The nurse included instructions to "apply betadine daily to DTIs." The same assessment for the three DTIs was reported on 01/28/2025, along with continued instructions to apply betadine daily to the wounds. On 01/28/2025, a new wound to the right medial shin was noted and described as a fluid-filled blister that had opened. The nurse noted "wound care to right shin." During the Interdisciplinary Group Meeting on 02/06/2024, a note from the RN dated 01/26/2025 read in part that "... Patient has a 5x3 blister on the inner aspect of the right calf. Bister is draining clear fluid. Redness noted around blister … Keflex 500 QID x10 days ordered by (APRN) …" A second note by the RN dated 02/03/2025 included "... Patient has a 3x5 wound on the anterior aspect of the right calf. Wound cleaned with sterile wound cleanser. Loose scab comes off when cleaning. Wet to dry dressing applied …" The plans of care for the benefit periods 10/09/2024 to 01/06/2025 and 01/07/025 to 04/06/2025 were reviewed. The plans of care did not include an order for Betadine or an order for wound care orders that included the frequency of how often the dressing was to be changed. During a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 2) on 02/06/2025, it was confirmed that the plan of care did not include Betadine for the topical treatment of the patient's deep tissue injuries or wound care orders that included the treatment and frequency of dressing changes.

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 and includes a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 20 of 20 (100%) clinical records reviewed revealed the agency did not ensure that the patient's progress was documented against the goals specified in the plan of care. AGENCY POLICY: The hospice's policy "Plan of Care (CL-1-10)" effective 02/20/2009 with the last revised date of 09/25/2020 read in part that " … A registered nurse coordinates the implementation of the plan of care … and is responsible for ensuring … ongoing evaluation and assessment of the provision of hospice care for the patient and family recommending to the IDT modifications to the plan of care based on patient/family/caregiver response to hospice services …" CLINICAL RECORD 1: The patient, who resided in an assisted living facility, elected the hospice benefit on 09/10/2024 with the diagnosis of Alzheimer's disease. The plans of care for the benefit periods 09/10/2024 to 12/08/2024 and 12/09/2024 to 03/08/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 11/13/2024, 11/27/2024, 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 2: The patient, who resided at home, elected the hospice benefit on 10/05/2024 with the diagnosis of neurocognitive disorder with Lewy Bodies. The plans of care for the benefit periods 09/29/2024 to 11/27/2024 and 11/28/2024 to 01/26/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 11/13/2024, 11/27/2024, 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 3: The patient, who resided at home, elected the hospice benefit on 12/19/2024 with the diagnosis of an unspecified lump in the left breast. The plan of care for the benefit period 12/19/2024 to 03/18/2025 was reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 01/02/2025, 01/16/2025, and 01/30/2025. CLINICAL RECORD 4: The patient, who resided at home, elected the hospice benefit on 07/25/2023 with the diagnosis of unspecified cirrhosis of the liver. The plans of care for the benefit periods 10/25/2024 to 12/23/2024 and 12/24/2024 to 02/21/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 11/15/2024, 11/29/2024, 12/13/2024, 12/27/2024, 01/10/2025, and 01/24/2025. CLINICAL RECORD 5: The patient, who resided at home, elected the hospice benefit on 10/09/2024 with the diagnosis of unspecified heart failure. The plans of care for the benefit periods 10/09/2024 to 01/06/2025 and 01/07/025 to 04/06/2025 were reviewed There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 10/31/2024, 11/14/2024, 11/17/2024, 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 6: The patient, who resided at home, elected the hospice benefit on 11/12/2024 with the diagnosis of Parkinson's disease. The plans of care for the benefit period 11/12/2024 to 02/09/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 12/13/2024, 12/27/2024, and 01/10/2025. CLINICAL RECORD 7: The patient, who resided at home, elected the hospice benefit on 12/05/2024 with the diagnosis of intrahepatic bile duct carcinoma. The plan of care for the benefit period 12/05/2024 to 03/04/2025 was reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 12/13/2024, 12/27/2024, and 01/10/2025. CLINICAL RECORD 8: The patient, who resided in a nursing facility, elected the hospice benefit on 02/13/2023 with the diagnosis of moderate protein-calorie malnutrition. The plans of care for the benefit periods 10/05/2024 to 12/03/2024 and 1204/2024 to 02/01/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 11/14/2024, 11/27/2024, 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 9: The patient, who resided at home, elected the hospice benefit on 04/05/2024 with the diagnosis of chronic obstructive pulmonary disease. The plans of care for the benefit periods 12/01/2024 to 01/29/2025 and 01/30/2025 to 03/30/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 10: The patient, who resided at home, elected the hospice benefit on 08/02/2024 with the diagnosis of malignant neoplasm of the posterior wall of the bladder. The plans of care for the benefit periods 10/31/2024 to 01/28/2025 and 01/29/2025 to 03/29/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 11/14/2024, 11/27/2024, 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 11: The patient, who resided at home, elected the hospice benefit on 09/28/2024 with the diagnosis of unspecified heart disease with the comorbid condition of chronic obstructive pulmonary disease. The plans of care for the benefit periods 09/28/2024 to 12/26/2024 and 12/27/2024 to 03/26/2025 was reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 11/14/2024, 11/27/2024, 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 12: The patient, who resided at a nursing facility, elected the hospice benefit on 09/24/2024. The plans of care for the benefit periods 09/24/2024 to 12/22/2024 and 12/23/2024 to 03/22/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 11/14/2024, 11/27/2024, 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 13: The patient, who resided at home, elected the hospice benefit on 01/02/2024 with the diagnosis of alcoholic cirrhosis of the liver. The plan of care for the benefit periods 10/28/2024 to 12/16/2024 and 12/27/2024 to 02/24/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for r 11/14/2024, 11/27/2024, 12/05/2024, 12/19/2024, 01/02/2025, 01/16/2025, and 01/29/2025. CLINICAL RECORD 14: The patient, who resided at home, elected the hospice benefit on 03/27/2023 with the diagnosis of Alzheimer's disease. The plans of care for the benefit periods 11/06/2024 to 01/04/2025 and 01/05/2025 to 03/05/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 11/14/2024, 11/27/2024, 12/12/2024, 12/26/2024, 01/09/2025, and 01/23/2025. CLINICAL RECORD 15: The patient, who resided at home, elected the hospice benefit on 07/16/2024 with the diagnosis of malignant neoplasm of the liver. The patient revoked hospice services on 10/25/2024. The plans of care for the benefit periods 07/16/2024 to 10/13/2024 and 10/14/2024 to 02/11/2025 were reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 07/18/2024, 08/01/2024, 08/15/2024, 08/29/2024, 09/12/2024, 09/26/2024, 10/10/2024, and 10/24/2024. CLINICAL RECORD 16: The patient, who resided at home, elected the hospice benefit on 06/17/2024 with the diagnosis of nonspecific abnormal finding of the lung field. He was discharged from hospice services on 09/05/2024 for an (extended prognosis). The plan of care for the benefit period 06/17/2024 to 09/14/2024 was reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 06/20/2024, 07/05/2024, 07/18/2024, 08/01/2024, 08/15/2024, and 09/02/2024. CLINICAL RECORD 17: The patient, who resided in a nursing facility, elected the hospice benefit on 02/01/2024 with the diagnosis of senile degeneration of the brain. She died while on hospice services on 07/05/2024. The plan of care for the benefit period 05/01/2024 to 07/29/2024 was reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 05/03/2024, 05/17/2024, 05/31/2024, 06/14/2024, and 06/28/2024. CLINICAL RECORD 18: The patient, who resided at home, elected the hospice benefit on 06/15/2024 with the diagnosis of malignant neoplasm of the pancreas. He died while on hospice services on 07/26/2024. The plan of care for the benefit period 06/15/2024 to 09/12/2024 was reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 06/27/2024, 07/11/2024, and 07/25/2024. CLINICAL RECORD 19: The patient, who resided in a nursing facility, elected the hospice benefit on 05/30/2024 with the diagnosis of senile degeneration of the brain. She died while on hospice services on 08/18/2024. The plan of care for the benefit periods 05/30/2024 to 07/78/2024 was reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 6/13/2024, 06/27/2024, 07/11/2024, and 07/25/2024. CLINICAL RECORD 20: The patient, who resided at home, elected the hospice benefit on 12/06/2024 with the diagnosis of senile degeneration of the brain. She revoked the hospice benefit on 12/15/2024. The plan of care for the benefit period 12/06/2024 to 03/05/2025 was reviewed. There was no documented evidence of progress toward the identified goals documented in the plan of care and/or Interdisciplinary Group Meetings for 12/12/2024. During a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 2) on 02/06/2025, she confirmed there was no documentation of the patient and/or family's progress toward the goals identified in the plan of care noted in each patient's plan of care and/or Interdisciplinary Group Meetings.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 15 (20%) clinical records in which the agency did not ensure the aide followed the plan of care. AGENCY POLICY: The agency policy entitled "Supervision of Services (CL-1-13)," effective 02/02/1995 and revised 12/2024, read in part that the purpose was to "... assure supervision of all direct care services by a qualified professional and to assure the plan of care is followed per written instructions of the … registered nurse … The RN will assess …services provided and whether the services ordered meet the patient's needs … The nurse will assess the aide's ability to … follow the patient's plan of care … report changes in the patient's condition …" CLINICAL RECORD 8: The patient, who resided in a nursing facility, elected the hospice benefit on 02/13/2023 with the diagnosis of moderate protein-calorie malnutrition. The plans of care for the benefit periods 10/18/2024 to 12/03/2024 and 12/04/2024 to 02/01/2025 included orders for the hospice aide to perform twice-weekly visits. The aide care plan in effect was dated 03/27/2023 and included the interventions: shower the patient twice a week, patient/family/caregiver may determine the type of personal care desired, i.e., shower versus partial bath versus bed bath, perform a bed bath if the patient/family/facility nurse request, provide perineal care every visit, clean nails every visit, provide oral hygiene every visit, apply deodorant and lotion every visit, and assist in dressing the patient every visit, change linens twice a week, and clean/straighten the patient area every visit During the aide's visit documented for 11/07/2024, it was noted that the intervention to provide a bed bath if the patient/family/facility nurse requested was refused. The interventions that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus partial bath versus bed bath and shower the patient twice a week, were marked as not applicable to the visit. A narrative stated, "The patient exhibits weakness and tires easily during care involving activities of daily living." There was no documentation that the aide notified the Registered Nurse (RN). During the aide's visit on 11/12/2024, patient refusal was noted for the interventions to be assisted with dressing, to be provided a bed bath if patient/family/facility nurse requested, to have linens changed, for nails to be cleaned or oral hygiene performed, perineal care done, to be showered, or to have deodorant and lotion applied. The aide documented in a narrative that the "patient refused all care. she was upset with facility staff and only wanted to visit and vent." There was no notification of the RN documented. Then, on 11/14/2024, the hospice aide noted that the patient refused to be assisted with dressing, to have linens changed, to have her nails cleaned, or to be showered. She declined to have deodorant or lotion applied. The intervention for a bed bath is to be given if the patient/family/facility nurse request was marked as not applicable to this visit. The aide's narrative included, "The patient exhibits weakness and tires easily during care involving activities of daily living." There was no documented evidence that the aide followed the aide care plan as written. CLINICAL RECORD 15: The patient, who resided at home, elected the hospice benefit on 07/16/2024 with the diagnosis of malignant neoplasm of the liver. The patient revoked hospice services on 10/25/2024. The plans of care for the benefit periods 07/16/2024 to 10/13/2024 and 10/14/2024 to 02/11/2025 included orders for the hospice aide to visit the patient twice a week. The active aide care plan was dated 07/16/2024. It included interventions that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus partial bath versus bed bath, to assist the patient in dressing every visit, cleaning/straightening the patient area every visit, brushing/styling the patient's hair every visit, providing oral hygiene every visit, making the bed every visit, and changing linens weekly. The following interventions on the aide care plan did not include a frequency: tub bath, shower, shampoo her hair, provide perineal care, and apply deodorant and lotion. During the visit performed on 10/11/2024 by the aide, she noted the refusal for the intervention for the patient/family/caregiver to determine the type of personal care desired, i.e., shower versus partial bath versus bed bath, and to shower the patient. The bed bath and tub bath were marked as not applicable to the visit. The aide's narrative stated that the "Pt weak and tires easily. Pt refused shower." There was no documented evidence that the aide followed the aide care plan as written. CLINICAL RECORD 19: The patient, who resided in a nursing facility, elected the hospice benefit on 05/30/2024 with the diagnosis of senile degeneration of the brain. She died while on hospice services on 08/18/2024. The plans of care for the benefit periods 05/30/2024 to 07/28/2024 and 07/29/2024 to 09/26/2024 included orders for the hospice aide to visit the patient three times a week. The hospice aide care plan was dated 05/31/2024. It included the interventions that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus patient bath versus bed bath, to provide a shower every visit, to provide a bed bath if the facility nurse or family request, to shampoo her hair every visit, clean her nails every visit, provide oral hygiene every visit, to assist the patient with dressing every visit, to apply lotion and deodorant every visit, provide perineal care every visit, to clean/straighten the patient area every visit, and to change the linens weekly. During the aide visits for 06/10/2024, 06/12/2024, 06/14/2024, and 06/17/2024, the interventions to shower the patient each visit and may provide a bed bath if the facility nurse or family request were marked as not applicable to the visits. The intervention that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus patient bath versus bed bath, was documented as completed. There was no documentation of what kind of bath/shower was provided to the patient, and there was no documentation that the registered nurse was notified. On both the aide visits on 08/02/2024 and 08/14/2024, the notes indicated that the following interventions were marked as not applicable: that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus patient bath versus bed bath, to shower the patient every visit, and that a bed bath may be provided if the facility nurse or family request. A narrative documented by the aide read, "The patient becomes weak and fatigues quickly during activities of daily living." There was no documented evidence that the aide followed the aide care plan as written. During an interview with the Clinical Director on 02/05/2025, it was confirmed that the aide visits were documented as presented in the evidence and against agency expectations. No further documentation was provided before the end of the site visit.

It is required that hospice aides must report changes in the patient’s, nursing 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, document review and interview. In 3 of 15 (20%) applicable clinical records in which hospice aide services were accepted revealed the agency did not ensure the aide notified the registered nurse when the plan of care was not completed as written or changes in the patient’s needs. AGENCY POLICY: The agency policy entitled "Supervision of Services (CL-1-13)," effective 02/02/1995 and revised 12/2024, read in part that the purpose was to "... assure supervision of all direct care services by a qualified professional and to assure the plan of care is followed per written instructions of the … registered nurse … The RN will assess …services provided and whether the services ordered meet the patient's needs … The nurse will assess the aide's ability to … follow the patient's plan of care … report changes in the patient's condition …" CLINICAL RECORD 8: The patient, who resided in a nursing facility, elected the hospice benefit on 02/13/2023 with the diagnosis of moderate protein-calorie malnutrition. The plans of care for the benefit periods 10/18/2024 to 12/03/2024 and 12/04/2024 to 02/01/2025 included orders for the hospice aide to perform twice-weekly visits. The aide care plan in effect was dated 03/27/2023 and included the interventions: shower the patient twice a week, patient/family/caregiver may determine the type of personal care desired, i.e., shower versus partial bath versus bed bath, perform a bed bath if the patient/family/facility nurse request, provide perineal care every visit, clean nails every visit, provide oral hygiene every visit, apply deodorant and lotion every visit, and assist in dressing the patient every visit, change linens twice a week, and clean/straighten the patient area every visit During the aide's visit documented for 11/07/2024, it was noted that the intervention to provide a bed bath if the patient/family/facility nurse requested was refused. The interventions that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus partial bath versus bed bath and shower the patient twice a week, were marked as not applicable to the visit. A narrative stated, "The patient exhibits weakness and tires easily during care involving activities of daily living." There was no documentation that the aide notified the Registered Nurse (RN). During the aide's visit on 11/12/2024, patient refusal was noted for the interventions to be assisted with dressing, to be provided a bed bath if patient/family/facility nurse requested, to have linens changed, for nails to be cleaned or oral hygiene performed, perineal care done, to be showered, or to have deodorant and lotion applied. The aide documented in a narrative that the "patient refused all care. she was upset with facility staff and only wanted to visit and vent." There was no notification of the RN documented. Then, on 11/14/2024, the hospice aide documented that the patient refused to be assisted with dressing, to have linens changed, to have her nails cleaned, or to be showered. She declined to have deodorant or lotion applied. The intervention for a bed bath is to be given if the patient/family/facility nurse request was marked as not applicable to this visit. The aide's narrative included, "The patient exhibits weakness and tires easily during care involving activities of daily living." There was no documented evidence that the aide notified the RN of the changes in the patient’s nursing needs. CLINICAL RECORD 15: The patient, who resided at home, elected the hospice benefit on 07/16/2024 with the diagnosis of malignant neoplasm of the liver. The patient revoked hospice services on 10/25/2024. The plans of care for the benefit periods 07/16/2024 to 10/13/2024 and 10/14/2024 to 02/11/2025 included orders for the hospice aide to visit the patient twice a week. The active aide care plan was dated 07/16/2024. It included interventions that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus partial bath versus bed bath, to assist the patient in dressing every visit, cleaning/straightening the patient area every visit, brushing/styling the patient's hair every visit, providing oral hygiene every visit, making the bed every visit, and changing linens weekly. The following interventions on the aide care plan did not include a frequency: tub bath, shower, shampoo her hair, provide perineal care, and apply deodorant and lotion. During the visit performed on 10/11/2024 by the aide, she noted the refusal for the intervention for the patient/family/caregiver to determine the type of personal care desired, i.e., shower versus partial bath versus bed bath, and to shower the patient. The bed bath and tub bath were marked as not applicable to the visit. The aide's narrative stated that the "Pt weak and tires easily. Pt refused shower." There was no documented evidence that the aide notified the RN of the changes in the patient’s nursing needs. CLINICAL RECORD 19: The patient, who resided in a nursing facility, elected the hospice benefit on 05/30/2024 with the diagnosis of senile degeneration of the brain. She died while on hospice services on 08/18/2024. The plans of care for the benefit periods 05/30/2024 to 07/28/2024 and 07/29/2024 to 09/26/2024 included orders for the hospice aide to visit the patient three times a week. The hospice aide care plan was dated 05/31/2024. It included the interventions that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus patient bath versus bed bath, to provide a shower every visit, to provide a bed bath if the facility nurse or family request, to shampoo her hair every visit, clean her nails every visit, provide oral hygiene every visit, to assist the patient with dressing every visit, to apply lotion and deodorant every visit, provide perineal care every visit, to clean/straighten the patient area every visit, and to change the linens weekly. During the aide visits for 06/10/2024, 06/12/2024, 06/14/2024, and 06/17/2024, the interventions to shower the patient each visit and may provide a bed bath if the facility nurse or family request were marked as not applicable to the visits. The intervention that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus patient bath versus bed bath, was documented as completed. There was no documentation of what kind of bath/shower was provided to the patient, and there was no documentation that the registered nurse was notified. On both the aide visits on 08/02/2024 and 08/14/2024, the notes indicated that the following interventions were marked as not applicable: that the patient/family/caregiver may determine the type of personal care desired, i.e., shower versus patient bath versus bed bath, to shower the patient every visit, and that a bed bath may be provided if the facility nurse or family request. A narrative documented by the aide read, "The patient becomes weak and fatigues quickly during activities of daily living." There was no documented evidence that the aide notified the RN of the changes in the patient’s nursing needs. During an interview with the Clinical Director on 02/05/2025, it was confirmed that the aide visits were documented as presented in the evidence and against agency expectations. No further documentation was provided before the end of the site visit.

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 primary terminal condition and related diagnosis(es), if any. This standard was not met as evidenced by clinical record review and interview. In 1 of 20 (5%) clinical records reviewed revealed the agency did not ensure that the physician's certification included the patient's correct terminal diagnosis. CLINICAL RECORD 15: The patient, who resided at home, elected the hospice benefit on 07/16/2024 with the diagnosis of malignant neoplasm of the liver. The patient revoked hospice services on 10/25/2024. The initial physician certification of terminal illness for the benefit period 07/16/2024 to 10/13/2024 was scanned into the clinical record with a handwritten narrative that included only the "Pt with Metastatic Bladder Cancer currently severe obstruction and pain. Pt in last few months of life would require hospice care." The patient's diagnosis was malignant neoplasm of the liver and was supported by the biopsy lab report included in the patient's history and physical scanned into the record. The information was confirmed as incorrect on the certification form during a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 2) on 02/06/2024.

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 20 (20%) clinical records reviewed revealed that the agency did not ensure that corrections made to clinical documentation was corrected with acceptable standards of practice. CLINICAL RECORD 2: The patient, who resided at home, elected the hospice benefit on 10/05/2024 with the diagnosis of neurocognitive disorder with Lewy Bodies. On the Election of Hospice Benefit form, the admission date and the election of benefits had the "5" written over and not initialed or dated. The patient and hospice representatives' signature date on page three had the "5" written over and not initialed or dated. CLINICAL RECORD 6: The patient, who resided at home, elected the hospice benefit on 11/12/2024 with the diagnosis of Parkinson's disease. On the third page of the Election of Benefits, the hospice representative's date of signature had the "12" written over and not initialed or dated. CLINICAL RECORD 9: The patient, who resided at home, elected the hospice benefit on 04/05/2024 with the diagnosis of chronic obstructive pulmonary disease. The initial hospice diagnosis located at the top of the form "Against Medical Advice Related to Swallowing/Eating/Fluid Restriction" form was scribbled out with no date or initials, and another diagnosis was written next to it. CLINICAL RECORD 18: The patient, who resided at home, elected the hospice benefit on 06/15/2024 with the diagnosis of malignant neoplasm of the pancreas. He died while on hospice services on 07/26/2024. On the top of the "Medication Disposal Acknowledgement Form," the medical record number was written over to correct the "9" and not initialed or dated. Also, the document entitled "Bereavement Assessment" (completed on paper) had the signature date of 09/23/2024 written over whiteout. During a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 2) on 02/05/2024, the findings on the forms were confirmed

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 1 of 2 (50%) applicable clinical records in which there was a live discharge from hospice care revealed the agency did not ensure that the patient's discharge summary was forwarded to the hospital upon the patient revoking services. CLINICAL RECORD 15: The patient, who resided at home, elected the hospice benefit on 07/16/2024 with the diagnosis of malignant neoplasm of the liver. The patient revoked hospice services on 10/25/2024. There was no documentation that the discharge summary was provided to the hospital, no note that a verbal report was given by the hospice nurse to the facility nurse or doctor on the discharge summary, in a collaboration note, during the post-discharge Interdisciplinary Group Meeting on 11/07/2024, or in a clinical note. It was confirmed during an interview with the Director of Clinical Services (Personnel Record 2) on 02/05/2024 that there was no documentation that the discharge summary and plan of care was provided to the hospital.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure that the patient's record included visit notes, including the care and services provided by the hospice aide. Clinical Record 5: The patient elected hospice care on 02/07/2023. The plan of care ordered hospice aide services "effective 02/20/2023...3 times a week." A review of the clinical record revealed no evidence of hospice aide visit notes for 02/20/2023 through 03/3/2023. There were no missed visits documented. During an interview on 03/06/2023, the Director of Quality Improvement and Compliance confirmed the finding stating the aide completed visits on 02/20/2023, 02/22/2023, 02/24/2023, 02/27/2023, 03/01/2023 and 03/03/2023, but there were no notes documented for the visits. No further documentation was provided by the agency as of the exit conference on 03/06/2023.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP 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; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; Documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by personnel record review and interview. 1 of 11 (9%) personnel records reviewed revealed the organization did not ensure that emergency preparedness (EP) training was provided to a hospice physician at the time of hire and/or every two years. Record #18629 was reviewed was reviewed and identified that the initial contract was signed on 4/27/2018. There was no evidence that the contracted medical diector completed EP training in 2018, 2019, 2020, 2021 or to date. The personnel record did not contain documented evidence the training was competed upon hire and every two years. The Alternate Administrator was interviewed on 5/4/2022 and agreed that EP training was not documented in the individual personnel record. She had no additional information to provide.

It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by clinical record review and interview. 5 of 13 (38%) clinical records reviewed revealed the organization did not ensure the record documented the execution of the patient's advance directive. Record # 37793 was reviewed and revealed that the patient elected the hospice benefit on 11/19/2021. There was no documented code status for the patient. The admission assessment documented that the "conversation occurred" but there was no documentation of the patient/primary care giver choice. Record # 72872 was reviewed and revealed that the patient elected the hospice benefit on 2/1/2022. There was no documented code status for the patient. The admission assessment documented that the "conversation occurred" but there was no documentation of the patient/primary care giver choice. Record #58963 was reviewed and revealed that the patient elected the hospice benefit on 10/14/2021. There was no documented code status for the patient. The admission assessment documented that the "conversation occurred" but there was no documentation of the patient/primary care giver choice. Record #22679 was reviewed and revealed that the patient elected the hospice benefit on 4/1/2022. There was no documented code status for the patient. The admission assessment documented that the "conversation occurred" but there was no documentation of the patient/primary care giver choice. Record # 13320 was reviewed and revealed that the patient elected the hospice benefit on 4/8/2022. There was no documented code status for the patient. The admission assessment documented that the "conversation occurred" but there was no documentation of the patient/primary care giver choice. The Director of Clinical Services was interviewed on 5/4/2022 and agreed that the advance directive information was not clearly documented in the clinical record. She had no additional information to provide.

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. 2 of 13 (15%) clinical records reviewed revealed the agency did not ensure the patient/family recieved an initial bereavement assessment. Record #58963 was reviewed and identified that the patient elected the hospice benefit on 10/14/2021. There was no evidence that an initial bereavement assessment was completed. Record #48601 was reviewed and identified that the patient elected the hospice benefit on 12/15/2020. There was no evidence that an initial bereavement assessment was completed. The Director of Clinical Services was interviewed on 5/3/2022 and agreed that the bereavement assessments were not complete. She had no additional information to provide.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. 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 personnel record review and interview. 1 of 11 (9%) personnel records reviewed revealed the agency did not ensure participation in infection control in-services for for a contracted physician. Record #18629 was reviewed and identified that the initial contract for the Hospice Medical DIrector was signed on 4/27/2018. There was no documented evidence of infection control training in the record. The Alternate Administrator was interviewed on 5/4/2022 and agreed that infection control in-services were not completed. She had no additional information to provide.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by personnel record review, document review and interview. 1 of 11 (9%) personnel records reviewed revealed that the hospice did not ensure licened professionals participated in in-service training in accordance with agency policy. Record #18629 was reviewed and identified that the Hospice Medical Director contract was established on 4/27/2018. There is no documentation in the personnel record of participation/completion of hospice sponsored in-service training in 2018, 2019, 2020, 2021, and to date at the time of this review on 5/4/2021. Policy: PR 1-19 Date: 2/1/1995 Title: Employee Development states in part "Educational in-services will be provided on a rolling 12 month period for direct patient care employees." The Alternate Administrator was interviewed on 5/4/2022. She agreed that there was no documentation in the personnel record for the contracted physician. She is currently working on a program to ensure that this education is provided to the contracted staff at hire and annually.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness and Education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by personnel record review and interview. 1 of 11 (9%) personnel records reviewed revealed the hospice did not ensure that an initial orientation was provided to a hospcie physician. Record #18629 was reviewed and identified that the contracted Hospice Medical Director's initial contract was established on 4/27/2018. There was no documented evidence that orientation was provided upon hire. The Alternate Administrator was interviewed on 5/4/2022. She agreed that there was no orientation documentation in the personnel record for the contracted physician. She is currently working on a program to ensure that this is completed with the contracted staff at hire.

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 the following: 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; 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. 3 of 3 (100%) applicable clinical records of live discharges reviewed revealed that the discharge summary did not include all required elements. Record #72872 was reviewed and revealed that the patient was discharged on 4/25/2022 for no longer meeting eligibility requirements. The EMR generated discharge summary completed on 4/25/2022 did not include a summary of the hospice stay, the POC or physician orders/medication profile. Record #14114 was reviewed and revealed that the patient was discharged on 1/8/2022 because of moving out of the service area. The EMR generated discharge summary completed on 1/8/2022 does not include a summary of the hospice stay, the POC or physician orders/medication profile. Record # 61519 was reviewed and revealed that the patient revoked the hospice benefit on 4/16/2022 to seek aggressive/curative care. The EMR generated discharge summary completed on 4/16/22 does not include a summary of the hospice stay, the POC or physician orders/medication profile. The Director of Clinical Service was interviewed on 5/4/2022 and agreed that the required items were not included in the discharge summary. She had no additional information to provide.

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. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by personnel record review, contract review and interview. 1 of 11 (9%) personnel records reviewed revealed the hospice did not obtain a criminal background check on a contracted physician who has direct patient contact and access to patient records. Record #18629 was reviewed and identified that the employee contracted with the hospice on 4/27/2019. The contract for the Medical Director states in part "3. Obligations of Hospice. g. Caregiver Background Checks. Hospice shall obtain a criminal background check on Medical Director in accordance with state and federal requirements. There is no documented evidence of a completed background check in the personnel record. The Alternate Administrator was interviewed on 5/4/2022. She agreed that there was no documentation of a completed background check in the personnel record for the contracted physician. She stated that this was a recently discovered error and is currently working on a program to ensure that background checks are completed on all contracted staff at hire and annually.