Every finding on record at Hospice Brazos Valley, Inc.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary; [and] the patient's record, if requested. This standard was not met as evidenced by the documentation review, the clinical record review and interview. 1 of 4 (25%) applicable records of discharged patients revealed no documentation that a discharge summary was sent to the attending physician. Record #63870: The certification period from 8/24/2021 through 10/22/2021- 80-year-old with a diagnosis of Alzheimer's and Hypertensive Heart Disease. The patient was discharged on 10/12/2021, being deemed to be no longer terminally ill. There was no documentation indicating that the attending physician was notified of the discharge or provided with a discharge summary. The policy, (Revised 5/20/2021) titled, ‘Discharge/Transfer/Revocation” read in part"...A discharge summary is completed and includes a summary of the patient's stay including treatments, symptoms, and pain management, and the patient's current plan of care and latest physician orders. Other documentation facilitating continuity of care and /or requested by the attending physician." In an interview with the Administrator on 10/21/2021, the Administrator stated that the agency had not sent the discharge summary.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident hospice medication information and physician certification and recertification of the terminal illness. This standard was not met as evidenced by the review of clinical records, observation and interview. 1 of 1 (100%) patient records present at a facility revealed the agency did not provide the Physician Certification of Terminal Illness and subsequent Recertification documentation. Record #44852: The Start of Care (SOC) from 7/13/2021 through 10/10/2021, and certification 10/11/2021 through 12/9/2021. The client's diagnosis included Metastatic Renal Cell Carcinoma, Parkinson's Disease, CHF and a status of being wheelchair bound. The hospice patient records located at the long-term skilled facility did not provide the Physician Certification of the Terminal Illness or the Recertification of the Terminal Illness. In an interview, the LMSW, who was present at the facility and participated in a joint patient record review, stated that they had been bringing copies of the certifications to the facility, but these were not present in the patient records. 1 of 1 (100%) of applicable records of patients in a long-term care facility who received Oxygen revealed that the agency did not provide documented evidence that the medication profile included Oxygen. Record #44852: The Start of Care (SOC) was on 7/13/2021, and the certification periods were from 7/13/2021 through 10/10/2021, and certification 10/11/2021 through 12/9/2021. The client diagnosis included Metastatic renal cell carcinoma, Parkinson's, CHF and a status of being wheelchair bound. The patient is on Oxygen 5 Liters per oxygen concentrator. This order was dated 7/13/2021. The Oxygen was not listed on the medication profile at the long-term care facility. The policy, (Revised 4/26/2021), “Care in the Nursing Facility” (C26) read in part” …[Agency] will provide the SNF/NF/llD with the following information: the most recent Plan of Care, Hospice election form, any Advanced Directives, Physician Certification and Recertification of the Terminal Illness specific to the patient, to include names and contact information of hospice personnel for delivery of hospice services, instructions on accessing 24-hour call, medications, and the Hospice physician and attending physician, including any orders specific to the patient.” In an interview, the Administrator stated that the medication profile had not been updated to include the Oxygen.

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 a review of documentation and interview. This revealed that the Pharmacy, Durable Medical Equipment and Long-term Care Facility contracts failed to include the clause, in writing, between the contractor/contractee, of the provision requiring criminal background checks. During an interview on 10/22/2021, the Administrator stated that an addendum would be provided to ensure contracts included the clause requiring Criminal background checks for all employees having direct contact with patients or their records.