Every finding on record at Hope & Grace Hospice, Inc.

It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise; or a mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not document a full-scale exercise that tested its emergency preparedness plan for the years 2020,2021,2022. The agency had documented an office base fire drill dated 11/20/2022 with the attendance of office personnel only. During an interview with the Administrator on 3/9/2023, it was stated the agency did not document past emergency preparedness exercises and confirmed the office base fire drill did not meet the community-based exercise requirements. The agency did not document a full-scale exercise that tested its emergency preparedness plan for the last 2-3 years. The agency had documented an office base fire drill dated 11/20/2022 with the attendance of office personnel only. Additionally, an interview with the Administrator on 3/9/2023 stated the agency did not document past emergency preparedness exercises and confirmed the office base fire drill did not meet the community-based exercise requirements.

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 following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. 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 observation. 3 of 3 (100%) home visits revealed that the medication profile comparisons were inaccurate based on medication reconciliation reviews. Home Visit 1: The patient, with the election of hospice benefits dated 1/27/2023, had a primary diagnosis of Alzheimer's and received hospice services at an assisted living facility. During the visit with the Registered Nurse (RN) on 3/8/2023, a medication reconciliation was performed, comparing the hospice medication profile provided on 3/7/2023 to the medication profile of the assisted living facility (ALF). The hospice profile documented Apixaban 5mg by mouth twice daily (BID) compared to the ALF profile documented a different dosage of 2.5mg, take one (1) tab by mouth twice daily (BID). The hospice medication profile was missing the Tylenol 500mg, two tablets by mouth every 6 hours as needed (PRN) for pain or fever listed on the ALF's medication profile. In addition, the hospice medication profile had documented Ativan 0.5mg 1-2 tablets by mouth every 4 hours as needed (PRN) for anxiety/agitation; however, the ALF's medication profile had three (3) duplicate orders for Ativan to include the order on the hospice profile and Ativan 1mg, 1-2 tablets by mouth every 4 hours as needed (PRN) for anxiety/agitation and Ativan 2mg bolus dose crushed by mouth limit two (2) doses, and call hospice after 2nd dose. The hospice medication profile documented Morphine sulfate concentrate 20mg/mL, take 0.25mL-1mL by mouth or sublingually every 1 hour as needed (PRN) for pain/dyspnea. However, the ALF medication profile documented that in addition to the hourly as needed (PRN) Morphine, a second order of Morphine 20mg/mL, give 1 mL bolus limit x2, and must call hospice after 2nd dose. Home Visit 2: The patient, with the election of hospice benefits dated 2/7/2023, had a primary diagnosis of metastatic colon cancer and received hospice services at an assisted living facility. During the visit with the hospice aide on 3/8/2023, a medication reconciliation was performed, comparing the hospice medication profile provided on 3/7/2023 to the medication profile of the assisted living facility (ALF). The ALF medication profile was missing the Ondansetron 8mg tablet by mouth every 8 hours as needed (PRN) for nausea or vomiting listed on the hospice medication profile. The ALF medication profile documented duplicate orders for Ativan and Morphine that were missing from the hospice medication profile, including Ativan 0.5mg, one (1) tablet by mouth every 4 hours as needed (PRN); Ativan 0.5mg, 1-2 tablets by mouth or sublingually every 4 hours as needed (PRN); Ativan 2mg, one (1) dose by mouth or sublingually, bolus limit 2, as needed (PRN); Morphine 20mg/mL 0.25mL-1mL by mouth or sublingually every 1 hour as needed (PRN); and Morphine 20mg/mL, 1 mL by mouth or sublingually bolus, limit 2, as needed (PRN). Home Visit 3: The patient, with the election of hospice benefits dated 1/11/2023, had a primary diagnosis of Alzheimer's and received hospice services at a personal care home. During the visit with the medical social worker on 3/8/2023, a medication reconciliation was performed, comparing the hospice medication profile provided on 3/7/2023 to the medication profile of the personal care home. As a result, the following medications were listed on the hospice medication profile but missing from the personal care home medication profile: Memantine 10mg, one (1) tablet by mouth daily for dementia; Aspirin 325mg, one (1) tablet by mouth daily for heart health; Travatan Z ophthalmic solution 0.004%, one (1) drop to both eyes (OU) daily for glaucoma; Simbrinza ophthalmic suspension 1-0.2%, one (1) drop to left eye twice daily for glaucoma; multi-vitamin one (1) tablet by mouth daily; Escitalopram oxalate 20mg by mouth daily for depression; and Vitamin D3 125 mcg, one (1) tablet by mouth daily.

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 (POC). This standard was not met as evidenced by clinical record review and interview. 5 of 11 (45%) records reviewed revealed the agency did not complete an initial bereavement assessment within five (5) days of the hospice start of care. Record 3: The patient with an election of hospice benefits dated 11/18/2022 did not have documented an initial bereavement assessment within five (5) days from the start of care. The Chaplain/Counselor Assessment dated 11/22/2022 had no documentation of bereavement assessment. The MSW Assessment, dated 11/25/2022, had no documentation of a bereavement assessment. The RN Initial Assessment dated 11/18/2022 had no documentation of a bereavement assessment. Record 4: The patient with an election of hospice benefits dated 12/20/2022 did not have documented an initial bereavement assessment within five (5) days from the start of care. The Bereavement assessment form dated 1/5/2023 had the status of "not started" and was not completed as of 3/9/2023. Record 7: The patient with an election of hospice benefits dated 2/11/2022 did not have documented an initial bereavement assessment within five (5) days from the start of care. In addition, the Chaplain's initial assessment dated 2/15/2022 and the chaplain assessment dated 2/23/2022 did not have a documented bereavement assessment. Record 9: The patient with an election of hospice benefits dated 1/27/2023 did not have a documented initial bereavement assessment within five (5) days from the start of care. The bereavement assessment dated 2/20/2023, as low risk of the daughter, was completed twenty-four (24) days after the start of care. Record 10: The patient with an election of hospice benefits dated 2/7/2023 did not have documented an initial bereavement assessment within five (5) days from the start of care. The Chaplain's initial assessment dated 2/08/2023 documented the daughter declined future bereavement services. However, a bereavement assessment was not completed or documented. During an interview with the Bereavement Coordinator on 3/9/2023, it was confirmed that bereavement POCs were not created.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 11 of 11 (100%) records reviewed revealed the agency did not include the medical supplies and/or appliances such as durable medical equipment (DME) on the Plan of Care (POC). Record 1: The patient with an election of hospice benefits dated 2/23/2022 had a primary diagnosis of Alzheimer's. The POC dated 2/15/2023 for the benefit period of 2/15/2023 through 5/15/2023 had been documented as blank under the supplies section. The written certification narrative signed by the medical director on 2/17/2023 documented bowel and bladder incontinence. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received wipes, gloves, and chuxs from the agency; however, the patient's son declined the agency's pull-ups. Record 2: The patient, with an election of hospice benefits dated 4/16/2020, had a primary diagnosis of hypertensive heart disease. The POC dated 1/20/2023 for the benefit period 1/31/2023 through 3/31/2023 documented the supplies section as blank. Additionally, the POC dated 11/25/2022 for the benefit period 12/02/2022 through 1/30/2023 documented the supplies section as blank. However, the DME items were documented on both of the POC. The written certification narrative signed by the medical director on 11/25/2022 and 1/20/2023 documented bowel and bladder incontinence. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received pull-ups, wipes, and chuxs. Record 3: The patient, with an election of hospice benefits dated 11/18/2022, had a primary diagnosis of congestive heart failure. The POC dated 11/25/2022 for the benefit period 11/18/2022 through 2/15/2023 documented the supplies section as blank. The written certification narrative signed by the medical director on 1/25/2022 documented bowel and bladder incontinence. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received pull-ups, wipes, gloves, and chuxs. Record 4: The patient, with an election of hospice benefits dated 12/29/2022, had a primary diagnosis of Lewy Bodies dementia. The POC dated 1/5/2023 for the benefit period 12/29/2022 through 1/11/2023 documented the supplies section as blank. The written certification narrative by the medical director, dated and signed on 1/6/2023, stated the patient was incontinent of bladder and bowel. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received pull-ups, wipes, gloves, and chuxs. Record 5: The patient, with an election of hospice benefits dated 8/4/2022, had a primary diagnosis of other frontotemporal neurocognitive disorder. The POC dated 8/5/2022 for the benefit period 8/4/2022 through 11/1/2022 documented the supplies section as blank; however, the DME was documented. The written certification narrative dated and signed on 8/5/20222 and 10/28/2022 by the medical director documented bladder and bowel incontinence. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received pull-ups, briefs, wipes, gloves, and chuxs. Record 6: The patient with an election of hospice benefits dated 2/23/2022 had a primary diagnosis of colon cancer. The POC dated 2/23/2022 and 7/22/2022 had the DME sections documented as blank, and no medical supplies listed. The Discharge - Death note dated 11/16/2022 documented that DME company was notified of the removal of equipment. The Alternate Administrator confirmed on 3/9/2023 that the patient received a hospital bed, oxygen 5L concentrator, nebulizer, wheelchair, and an over-bed table for DME. Additionally, the Assistant Director of Nursing confirmed on 3/9/2023 that the patient received from the agency briefs, wipes, gloves, chuxs, and split gauze. Record 7: The patient, with an election of hospice benefits dated 2/11/2022, had a primary diagnosis of congestive heart failure. The POC dated 2/18/2022 for the benefit period 2/11/2022 through 5/11/2022 had no documented medical supplies; however, the DME was documented. The written certification narrative dated and signed by MD on 2/18/2022 documented patient was incontinent of bowel and bladder. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received briefs, wipes, gloves, and chuxs. Record 8: The patient, with an election of hospice benefits dated 3/24/2022, had a primary diagnosis of Parkinson's. The POC dated 3/24/2021 for the benefit period 3/24/2021 through 6/21/2021 documented the DME but no medical supplies. The written certification narrative dated and signed by the medical director on 4/6/2021 documented incontinence of bladder and bowel. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received briefs, wipes, oral swabs, and chuxs. Record 9: The patient, with an election of hospice benefits dated 1/27/2023, had a primary diagnosis of Alzheimer's. The POC dated 2/3/2023 for the benefit period 1/27/2023 through 4/26/2023 documented the supplies section as blank; however, the DME was documented. The written certification narrative dated and signed by the medical director on 2/3/2023 documented incontinence of the bladder and bowel. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received incontinence supplies from the assisted living facility where the patient resided. Record 10: The patient, with an election of hospice benefits dated 2/7/2023, had a primary diagnosis of metastatic colon cancer. The POC dated 2/7/2023 for the benefit period 2/7/2023 through 5/7/2023 documented the supplies section as blank; however, the DME was documented. The written certification narrative dated and signed by the Medical Director on 2/17/2023 documented incontinence of the bladder and bowel. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received incontinence supplies from the assisted living facility where the patient resided. Record 11: The patient, with an election of hospice benefits dated 1/11/2023, had a primary diagnosis of Alzheimer's. The POC dated 2/3/2023 for the benefit period 2/5/2023 through 4/5/2023 documented the supplies section as blank; however, the DME was documented. The written certification narrative dated and signed by MD on 1/20/2023 documented patient was incontinent of bowel and bladder. The Assistant Director of Nursing confirmed on 3/9/2023 that the patient received briefs, wipes, gloves, and chuxs.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review, clinical record review and interview. 4 of 4 (100%) records reviewed where bereavement services were accepted revealed the agency did not adhere to their bereavement policy or create bereavement Plans of Care (POC) that included the types of bereavement services to be offered and the frequency of service delivery. The agency policy number TX.26, titled Bereavement and revised on 2/1/2013, stated in part..."Following the death, the Agency will develop and implement the bereavement POC based on the post death risk assessment...(6) The POC will include delineation of services and frequency to be provided, which may include, but not be limited to, the following: Contact with the family through cards, phone calls, and letters; Attendance at the funeral, when possible; Visits; Referral to counseling resources and physician for bereaved family members/significant others at high risk for pathological grief or experiencing complicated or severe grief or who have special needs." Record 3: The patient, with an election of hospice benefits dated 11/18/2022, revocated from the agency's services effective 1/19/2023 but later expired at a local hospital. The post-death IDT Meeting documented that the patient revocated to the hospital per the son's request and passed away in the hospital on 1/21/2023. The Bereavement Coordinator documented "bereavement assessment completed for monthly communication." An interview with the Bereavement Coordinator on 3/9/2023 stated that because the patient came off the agency's service before death, she did not know she could follow up with the son. She noted the son had requested to be followed by bereavement services. There was no follow-up documentation, a bereavement POC, or grief services provided to the son. Record 5: The patient with an election of hospice benefit dated 8/4/2022 expired on the agency's services on 12/27/2022. The bereavement assessment dated 1/4/2023 was documented as a medium risk level for the bereaved. There was no documented bereavement POC with the types of bereavement services to be offered or the frequency of service delivery. Record 6: The patient with an election of hospice benefits dated 2/23/2022 expired on the agency's services on 11/16/2022. There was no documented bereavement plan of care with the types of bereavement services to be offered or the frequency of service delivery. Record 8: The patient with an election of hospice benefit dated 3/24/2022 expired on the agency's services on 9/7/2022. The post-death IDT meeting dated 9/16/2022 did not document the bereavement risk level of the bereaved. There was no documentation of the declination of bereavement services, a post-death bereavement assessment, or a bereavement POC with the types of bereavement services to be offered or the frequency of service delivery. During an interview with the Bereavement Coordinator on 3/9/2023, it was confirmed that bereavement POCs of care were not created.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) records reviewed for which a hospice aide was accepted revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide's scope of practice. Record 1: The patient with an election of hospice benefits dated 2/15/2023 was receiving hospice aide services one time a week (1xW). The Aide Care Plan dated 2/15/2023 assigned two types of baths: complete bed bath every visit/as needed and partial bath/shower every visit. During an interview with the Assistant Director of Nursing (ADON) on 3/8/2023, it was stated that she created the aide plan and added both bath types because the patient was declining in status on admission.

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 (POC) 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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) records reviewed where hospice aide services were accepted revealed the hospice aide did not report to the Registered Nurse (RN) that tasks were not performed, per the care plan. Record 6: The patient with an election of hospice benefits dated 2/23/2022 received hospice aide services once a week (1xW). The Hospice Aide Care Plan, dated 2/23/2022, documented assigned tasks to be completed each visit, including showering 1xweek, combing/brushing, shampooing 1xweek, brushing teeth, pericare, assisting with dressing, assisting with ambulation, assisting with transfers, making the bed, change linens, and tidy patient care area. The Hospice Aide Visit Notes dated 2/25/2022, 3/4/2022, 3/11/2022, 3/18/2022, 3/25/2022, 4/1/2022, 4/8/2022, 4/15/2022, and 4/22/2022 documented "D" for "declined by patient/family/facility staff" and the following assigned tasks were not completed including a shower, shampoo, brush teeth, make the bed, and change linens. There was no documentation or evidence of reporting to the RN for any of the nine (9) hospice aide notes. During an interview and joint record review on 3/8/2023, the Assistant Director of Nursing and Administrator/DON confirmed that the hospice aide documented the assigned tasks as "declined" for nine (9) weeks without being reported to the registered nurse.

It is required that Volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: noted in the plan of care and documented in the patient record, including the time spent. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by a review of administrative documents, and interview. The agency did not utilize volunteers to support administrative and patient care services (HCDT.21.I/644). The agency failed to provide volunteer services used in day-to-day adminstrative and/or direct patient care roles for the Conditions of Participation CFR 418.78, Volunteers. The cumulative effect of these deficiencies could impact the organization's ability to ensure the provision of high quality care and services. During an interview on 3/9/2023 with the Administrator, with the dual role of Volunteer Coordinator (VC), it was stated the agency had no active volunteers since June 2022. The last volunteer with a hire date of 4/21/2021 resigned due to a school schedule conflict. During the eleven clinical records reviewed, there was no documentation or evidence of volunteer assessments of needs, including requests or declination of volunteer services. The Administrator/VC provided volunteer hours for the first and second Quarters of 2022 with 108 hours and 15 minutes. The agency form titled IDT Meeting Minutes contained a section titled Volunteer Activities that was documented as "ongoing," however, the Administrator/VC stated that it was recorded in error since there were no active volunteers.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the Plan of Care (POC) and documented in the patient record, including the time spent. This standard was not met as evidenced by document review and interview. During an interview on 3/9/2023 with the Administrator, with the dual role of Volunteer Coordinator (VC), it was stated the agency had no active volunteers since June 2022. The last volunteer with a hire date of 4/21/2021 resigned due to a school schedule conflict. During the eleven clinical records reviewed, there was no documentation or evidence of volunteer assessments of needs, including requests or declination of volunteer services. The Administrator/VC provided volunteer hours for the first and second Quarters of 2022 with 108 hours and 15 minutes. The agency form titled IDT Meeting Minutes contained a section titled Volunteer Activities that was documented as "ongoing," however, the Administrator/VC stated that it was recorded in error since there were no active volunteers. An interview on 3/9/2023 with the Administrator with the dual role of Volunteer Coordinator (VC) stated the agency had no active volunteers since June 2022. The last volunteer with a hire date of 4/21/2021 resigned due to a school schedule conflict. During the eleven clinical records reviewed, there was no documentation or evidence of volunteer assessments of needs, including requests or declination of volunteer services. The Administrator/VC provided volunteer hours for the first and second Quarters of 2022 with 108 hours and 15 minutes. The agency form titled IDT Meeting Minutes contained a section titled Volunteer Activities that was documented as "ongoing," however, the Administrator/VC stated that it was recorded in error since there were no active volunteers. The agency was to onboard a new volunteer the last week. However, the Administrator stated that the new volunteer did not attend orientation and could not be contacted.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes any advance directives. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) records reviewed revealed the agency did not have accurate advance directives documented for the patient. Record 1: The patient with an election of hospice benefits dated 2/15/2023 had a primary diagnosis of Alzheimer's. However, the patient did not have the State specific form titled Out of Hospital DNR (OOHDNR) on file despite the physician order dated 2/15/2023 documenting "Code: Pt has signed OOHDNR document." During an interview on 3/8/2023 with the Assistant Director of Nursing, who completed the admission, it was stated that the OOHDNR form was not in record.

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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) records reviewed where the patients were discharged or transferred to Medicare-certified facilities revealed the agency did not forward a copy of the hospice discharge summary. Record 3: The patient, with an election of hospice benefits dated 11/18/2022, had been discharged from the agency by choosing revocation of services. The Revocation Statement note dated and signed by Registered Nurse (RN) on 1/19/2023 documented, "patient's son sent the patient to the hospital due to acute kidney injury, she was deemed to have acute kidney failure (AKF), anuresis and was admitted to hospital. Son was pursuing aggressive treatment and opted revocation from hospice to have his mother treated." However, there was no documentation or evidence of the discharge summary or information sent to the receiving hospital. During an interview on 3/9/2023 with the Assistant Director of Nursing, it was confirmed the agency did not forward a hospice discharge summary as required.

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; 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. 3 of 3 (100%) records reviewed that were live discharges from the agency revealed the agency did not document discharge summaries that included 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; and any other documentation that will assist in the post-discharge continuity of care. Record 3: The patient, with an election of hospice benefits dated 11/18/2022, had been discharged from the agency by choosing revocation of services. The Revocation Statement note dated and signed by RN on 1/19/2023 documented, "patient's son sent the patient to the hospital due to acute kidney injury, she was deemed to have acute kidney failure (AKF), anuresis and was admitted to hospital. Son was pursuing aggressive treatment and opted revocation from hospice to have his mother treated." However, there was no documented evidence of a discharge summary created with the required elements or information sent to the receiving hospital. Record 4: The patient, with an election of hospice benefits dated 11/18/2022, had been discharged from the agency by choosing revocation of services. The discharge note dated 1/11/2023 documented the patient was to move to a non-contracted assisted living facility and receive curative physical therapy treatment. There was no documented evidence that a discharge summary was created with the required elements. Record 7: The patient, with an election of hospice benefits dated 11/18/2022, had been discharged from the agency due to transferring to another hospice agency. The discharge note dated 10/10/2022 lacked the required elements of a discharge summary. During an interview on 3/9/2023 with the Assistant Director of Nursing, it was confirmed that the discharge summary was not documented with the required elements during the joint records review.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are identified in the Plan of Care (POC) and provided to a patient while under the care of the hospice. This standard was not met as evidenced by observation and interview. 2 of 3 (67%) home visits observed revealed the agency did not provide the patients with medical supplies. Home Visit 1: The patient, with an election of hospice benefits dated 1/27/2023, had a primary diagnosis of Alzheimer's and incontinence of bowel and bladder. The patient received hospice services at an assisted living facility, and the hospice did not provide medical supplies needed for the patient, such as briefs, wipes, chuxs, or gloves. The assisted living facility provided the needed medical supplies to the patient. Home Visit 2: The patient, with an election of hospice benefits dated 2/7/2023, had a primary diagnosis of colon cancer with metastasis and incontinence of the bowel and bladder. The patient received hospice services at an assisted living facility, and the hospice did not provide medical supplies needed for the patient, such as briefs, wipes, chuxs, or gloves. During an interview on 3/8/2023 with the hospice aide during the Home Visit 2, it was stated that the assisted living facility provided the medical supplies for the patients. However, the agency did supply the disposable chuxs. During an interview on 3/8/2023 with the Administrator/Director of Nursing it was stated the facility had refused the agency to provide the medical supplies during the pandemic due to infection control reasoning.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review and interview. 1 of 3 (33%) records reviewed where the patients died on the agency's services revealed the agency did not document the disposal or disposition of controlled medications. Record 6: The patient with an election of hospice benefits dated 2/23/2022 received hospice services at an assisted living facility and expired on 11/16/2022. The patient had one controlled medication of Ativan 0.5mg by mouth daily four times daily (QID) on the Plan of Care (POC) order dated 9/16/2022 for the benefit period 9/21/2022 through 11/19/2022. However, the Discharge - Death RN note dated 11/16/2022 had no documentation of the disposal of medications, and the section was blank. During an interview with the Assistant Director of Nursing, it was confirmed that the controlled medication disposal was not documented and that the nurse should have recorded the disposition of the facility disposing of the medications per their protocol.