Every finding on record at Hospice Del Sol, LLC

It is required that during the initial assessment visit and in advance of providing care the hospice provides the patient—or his or her representative—with verbal and written notice of the patient’s rights and responsibilities. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the clinical record contained documentation that the patient or their representative had been informed of the patient’s rights and responsibilities. Clinical Record 6: The patient elected the hospice benefit on 11/12/2023 with a terminal diagnosis of malignant neoplasm of the pancreas. During the initial assessment, the patient signed a form titled Acknowledgment, that stated “I acknowledge and agree to the terms and conditions described in the following sections and documents." The form had a long list that included boxes next to the titles. One of the boxes was associated with the statement “Patient Rights and Responsibilities.” None of the boxes had been checked. The clinical record contained no documented evidence that the patient had been informed of the patient's rights and responsibilities, when this section of the form was left blank. During a joint clinical record review and interview on 02/04/2024, the Administrator /Director of Nursing stated all the boxes on the form should have been "checked during the admission process."

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the interdisciplinary group completed the initial comprehensive assessment no later than 5 calendar days after the election of hospice care. Clinical Record 9: The patient elected the hospice benefit on 10/06/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery. Clinical record review revealed the Social Worker completed the initial psychosocial assessment, as part of the initial comprehensive assessment on 10/13/2023, 7 days after the election of benefit, and 2 days outstanding. During a joint clinical record review and interview on 02/04/2024, the Administrator /Director of Nursing agreed the assessment was outside of the 5-day window and a note was not located to describe the delay.

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 (Registered Nurse) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 5 of 12 (42%) clinical records reviewed with aide services provided, the agency did not ensure the RN prepared complete written patient care instructions for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 01/23/2024 with a terminal diagnosis of senile degeneration of the brain. The initial nursing assessment dated 01/23/2024 included documentation that the patient was on oxygen continuously at 2 liters per minute and had a skin tear on the right forearm covered with dry dressing. The aide care plan did not include instructions for the aide related to the patient’s use of oxygen including if the oxygen could be removed during cares provided by the aide and did not include instructions related to the patient’s skin tear and dry dressing. The aide care plan assignment dated 01/23/2024 assigned three different types of baths, partial bed bath, complete bed bath, and shower. The aide care plan assignment did not provide the aide with specific instructions or criteria to determine the type of bath that should be performed. Clinical Record 3: The patient elected the hospice benefit on 01/14/2022 with a terminal diagnosis of cerebral infarction. The nursing assessment dated 08/21/2023 included documentation that the patient was on oxygen at 3 liters per minute continuously and had a wound on the left elbow covered with a dry dressing. The aide care plan did not include instructions for the aide related to the patient’s use of oxygen including if the oxygen could be removed during cares provided by the aide and did not include instructions related to the patient’s wound and wound dressing. Clinical Record 4: The patient elected the hospice benefit on 01/20/2024 with a terminal diagnosis of heart disease. The initial nursing assessment dated 01/20/2024 included documentation that the patient had a chronic ulcer to left lower extremity and oxygen continuously at 2 liters per minute. The aide care plan dated 01/20/2024 did not include instructions for the aide related to the patient’s use of oxygen including if the oxygen could be removed during cares provided by the aide and did not include instructions related to the patient’s chronic ulcer to the left lower extremity. Clinical Record 12: The patient elected the hospice benefit on 11/17/2023 with a terminal diagnosis of cerebral infarction. The aide care plan assignment dated 11/21/2023 assigned three different types of baths, partial bed bath, complete bed bath, and shower. The aide care plan assignment did not provide the aide with specific instructions or criteria to determine the type of bath that should be performed. Clinical Record 13: The patient elected the hospice benefit on 10/18/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 10/18/2023 included documentation that the patient was on oxygen continuously at 3 liters per minute. The aide care plan dated 10/18/2023 did not include instructions for the aide related to the patient’s use of oxygen including if the oxygen could be removed during cares provided by the aide. During a joint clinical record review and interview on 02/04/2024, Administrator /Director of Nursing confirmed specific instructions for the oxygen had not been included in the aide care plans.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 12 (8%) clinical records reviewed with aide services provided, the agency did not ensure the aide was providing services as ordered and included in the plan of care. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 01/14/2022 with a terminal diagnosis of cerebral infarction. The aide care plan dated 01/15/2022 assigned the aide the tasks of "complete bed bath, shave and dressing patient." During the home visit observation with the aide, the aide stated I provide a shower to the patient. During a joint clinical record review and interview on 02/04/2024, the Administrator /Director of Nursing confirmed that the aide care plan had assigned a complete bed bath, not a shower.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 12 (33%) clinical records reviewed with aide services provided, the agency did not ensure the Hospice Aide reported changes in the patient's condition or refusal of assigned tasks to the Registered Nurse. Clinical Record 4: The patient elected the hospice benefit on 01/20/2024 with a terminal diagnosis of heart disease. The aide care plan dated 01/20/2024 assigned the aide the tasks of “assist with feeding and shave.” The Hospice Aide documented on the visit note 01/29/2024 "not needed" for the tasks of “assist with feeding and shave.” The clinical record contained no documented evidence the aide notified the RN of the tasks not completed during the visit. Clinical Record 7: The patient elected the hospice benefit on 12/16/2022 with a terminal diagnosis of neurocognitive disorder with Lewy bodies. The aide care plan dated 12/16/2022 assigned the aide the tasks of “shampoo every visit, shave, and assist with feeding.” Clinical record review revealed the aide visit notes dated 01/22/2024, 01/23/2024, 01/25/2024, 01/26/2024, and 01/27/2024 included documentation that stated "not today" for the tasks of shampoo. On the aide visit noted dated 01/22/2024 the aide documented "not needed" for the tasks of assist with feeding and shave. The clinical record contained no documented evidence that the aide notified the RN of the tasks not completed during the visits. Clinical Record 12: The patient elected the hospice benefit on 11/17/2023 with a terminal diagnosis of cerebral infarction. The aide care plan dated 11/17/2023 assigned the aide the tasks of “shower, skin care, shampoo, peri care, skin care every visit.” On the aide visit notes dated 11/24/2024 and 11/28/2024 the aide documented the patient refused shower, skin care, shampoo, peri care. The clinical record contained no documented evidence that the aide notified the RN of the tasks not completed during the visits. Clinical Record 13: The patient elected the hospice benefit on 10/18/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The aide care plan dated 10/18/2023 assigned the aide the task of “assist with feeding every visit.” On the aide visit note dated 10/31/2023 the aide documented the patient refused the assist with feeding task. The clinical record contained no documented evidence that the aide notified the RN of the task not completed during the visit. During a joint clinical record review and interview on 02/04/2024, the Administrator /Director of Nursing confirmed the clinical record did not include documentation that the aide notified the nurse of the refused or missed tasks.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by personnel record review and interview. In 1 of 8 (12%) personnel records reviewed, the agency did not ensure documentation of the employee’s initial orientation. Personnel Record 4: Registered Nurse date of hire 08/15/2023. Personnel record review revealed no documented evidence of a job-specific initial orientation. During joint personnel record review and interview on 02/04/2024, the Administrator /Director of Nursing confirmed the initial orientation for the employee was not present in the personnel record.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 3 of 8 (38%) personnel records reviewed, the agency did not ensure skills and competencies were assessed for individuals providing care. Personnel Record 1: Medical Director date of hire 06/01/2022. Personnel record review revealed no documented evidence of competency assessment. Personnel Record 2: Administrator /Director of Nursing date of hire 05/09/2016. Personnel record review revealed no documented evidence that a competency assessment has been completed since 05/14/2021. Personnel Record 8: Volunteer date of hire 12/17/2019. Personnel record review revealed no documented evidence that a competency assessment has been completed since 04/07/2021. During joint personnel record review and interview on 02/04/2024, the Administrator /Director of Nursing stated the competencies were not present in the records but "we changed our policies on how often we need to do them."

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed with recertification, revealed the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. Clinical Record 5: The patient elected the hospice benefit on 07/21/2022 with a terminal diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the fourth benefit period started on 12/18/2022 and the recertification of terminal illness was signed by the physician on 12/27/2022, 9 days after the start of the benefit period, and 7 days outstanding. During joint clinical record review and interview on 02/04/2024, the Administrator /Director of Nursing confirmed the recertification of terminal illness was signed after the 2-day timeframe.

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. In 1 of 2 (50%) clinical records reviewed with patient discharge, the agency did not ensure the discharge summary provided to the patient's attending physician included the patient's current plan of care. Clinical Record 11: The patient elected the hospice benefit on 06/10/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The patient was discharged on 04/6/2023 for extended prognosis. Review of the discharge summary dated 04/06/2023 revealed it did not include the patient's current plan of care. During a joint clinical record review and interview on 02/04/2024, the Administrator /Director of Nursing confirmed the plan of care was not included in the discharge summary.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by personnel record review and interview. In 2 of 8 (25%) personnel records reviewed, the agency did not ensure criminal background checks were completed for all hospice employees with direct patient contact or access to patient records. Personnel Record 1: Medical Director date of hire 06/01/2022. Personnel record review revealed no documented evidence that a criminal background check was completed for this direct care employee. Personnel Record 4: Registered Nurse date of hire 08/15/2023. Personnel record review revealed no documented evidence that a criminal background check was completed for this direct care employee. During joint personnel record review and interview on 02/04/2024, the Administrator /Director of Nursing confirmed the background checks were not present in the personnel files.