Every finding on record at Hospice of Hope, LLC

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 3 of 5 (60%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions that included specific details based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 1: The initial nursing assessment dated 09/13/2023 reported "The patient was receiving oxygen 2 L/min via nasal cannula prn for shortness of breath (SOB)." The interdisciplinary group (IDG) POC dated 09/13/2023 had a respiratory goal for the problem "Altered breathing - SOB" and an intervention that stated, "Collaborate with physician, obtain order for oxygen prn", and "Instruct PCG in oxygen use". The record lacked evidence of the IDG POC having included the specific details for the oxygen settings to be taught to the patient's caregivers. CLINICAL RECORD 2: The initial nursing assessment dated 02/04/2025 reported "Patient's sister whom he lives with was scared to have him come back to her home due to aggression and agitation." The initial IDG POC dated 02/04/2025 lacked goals and interventions for aggression and agitation. CLINICAL RECORD 4: The initial nursing assessment dated 12/27/2024 reported "4 wounds - Right buttocks; Left buttocks; right lower extremity, and sacrum." The orders for each wound included, "Right buttock: site cleansed with wound cleanser and padded dry with gauze. Dynogel applied to wound bed and covered with calcium alginate dressing and dry alleyvyn dressing. Left buttock: cleanse with wound cleanser and padded dry. Dynogel and calcium alginate dressing applied to wound bed and covered with large alleyvyn dressing. Right lower extremity: site cleansed with wound cleanser and padded dry with gauze. Vaseline gauze applied to sites and covered with kerlix dressing. Sacrum wound site cleansed with wound cleanser and padded dry with gauze. Dynogel applied to wound bed and covered with calcium alginate dressing and dry alleyvyn dressing". The IDG POC dated 12/27/2024 had a goal "Alteration in skin/membrane integrity as evidenced by multiple irregular-sized stage 3 ulcers." There was an intervention that stated "Provide wound care per physician orders. Educate caregivers on wound treatment to be performed on non-nursing days". The record lacked evidence of the IDG POC having included the specific wound care to be provided by the nurse for each wound, and the specific wound care to be taught to the patient's caregivers. The Administrator and Director of Care Services (DPCS) stated in an interview on 02/19/2025 that the agency did not ensure the POC reflected patient and family goals and interventions that included specific detail based on problems identified in the initial and updated comprehensive assessments. CONTINUATION OF REQUIRED ACTION

It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff and patient population, with attention to their mobility and describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by interviews, and document review which revealed the hospice: Failed to ensure hospice develop and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served{HSEP.2.D/E4/ 418.113(a) }; Failed to ensure hospice develops and maintained an emergency preparedness plan that is reviewed and updated at least every two(2) years that includes evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served {HSEP.2.D/E6/ 418.113(a)(1)}; Failed to ensure 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 {HSEP.5. D/E36/ 418.113(d)}; and Failed to ensure the hospice emergency preparedness training of all hospice employees and individuals providing services under arrangement at least every two (2) years {HSEP 5. D/E37/ 418.113(d)(1)}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview revealed the Agency's emergency preparedness (EP) plan review was in 2022, with the last all-hazards risk assessment. There was no documented evidence that the emergency plan was reviewed for 2024. During an interview on 01/09/2025, the Administrator confirmed that the emergency preparedness (EP) plan was not reviewed and updated at least every two (2) years. The Administrator stated that the 2024 risk assessment would be completed and discussed at the following 2025 meeting. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of the emergency plan reviewed for 2024. The previous emergency plan review was in 2022, with the last all-hazards risk assessment.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview revealed the agency’s emergency preparedness (EP) plan lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for 2024. During an interview on 01/09/2024, the Administrator confirmed that a documented hospice-based and community-based risk assessment was not completed every two years using an “all-hazards” approach specific to the geography and population served. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for 2024.

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. This standard was not met as evidenced by document review and interview revealed the Agency’s emergency preparedness (EP) plan lacked documented evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and communication plan. The previous emergency plan review was in 2022. There was no documented evidence that the training program was updated for 2024. During an interview on 01/09/2025, the Administrator confirmed that a documented emergency preparedness training program was not based on a current risk assessment and was not reviewed and updated at least every two (2) years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and communication plan. The document lacked evidence of a risk assessment for 2024. The documentation lacked evidence that the training program was updated for 2024. The previous emergency plan review was in 2022.

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, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years, more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review and interview that revealed the Agency’s emergency preparedness (EP) plan lacked documented evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. There was no documented evidence of a risk assessment training program update for 2024. The previous emergency plan review was in 2022. During an interview on 01/09/2025, the Administrator confirmed that a documented emergency preparedness training program was not based on the emergency preparedness plan, risk assessment, policies and procedures, and communication plan. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for 2024. The documentation lacked evidence that the training program was updated for 2024. The most recent emergency plan review was 02/12/2024. The previous emergency plan review was in 2022.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the organization did not ensure the Interdisciplinary Group (IDG) completed an initial psychosocial and bereavement assessment no later than five calendar days after the election of hospice care. CLINICAL RECORD 1: The patient's date of the election was 07/02/2024. The medical social worker (MSW) phone visit note dated 07/03/2024 documented, "MSW made phone contact with patient regarding community resources for grief support groups. Patient was given resources for online grief support groups and encouraged to contact MSW if additional resources are needed." The psychosocial and bereavement assessments were dated 07/18/2024 (16 days). The clinical record lacked evidence that psychosocial and bereavement assessments occurred no later than five calendar days after the election of hospice care. During a joint record review and an interview on 01/09/2025, the Administrator and Director of Nursing agreed there was no documented evidence that the initial psychosocial and bereavement assessments were completed no later than five calendar days after the election of hospice care.

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, 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, 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, observation, and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 1: The patient's date of election was 09/13/2023. The patient resided in an assisted living facility (ALF). The Medication Profile (Clinical Record 9) dated 01/07/2025 revealed Gabapentin 100mg capsule, two capsules oral three times daily. During the home visit (Home Visit 1) on 01/08/2025 with the Hospice Aide (Personnel Record 10), the medications record at the facility revealed Gabapentin 300mg capsule, one capsule three times a day, started on 07/05/2024; Saline spray nasal solution, one spray each nostril every four hours as needed for nasal congestion, started on 05/13/2024; Cepacol sore throat mouth/throat lozenge, one by mouth every two hours as needed for sore throat, started on 05/13/2024; Tylenol Extra Strength 500mg tablet, two tablets by mouth every six hours as needed for fever, temp >99 degrees, started 11/11/2022; ASA tablet chewable 81mg tablet, one tablet by mouth daily, started 04/09/2021; and Milk of Magnesia 400mg/5ml, 30ml by mouth every 24 hours as needed for constipation, started 06/07/2023. The facility nurse verified each medication. The clinical record lacked documented evidence that the medication reconciliation was completed, and medications updated to the medication profile. HOME VISIT 2: The patient's date of election was 05/04/2024. The Medication Profile (Clinical Record 2) dated 01/07/2025 revealed Ativan 0.5mg tablet, one tablet oral three times a day as needed for anxiety/agitation. During the home visit (Home Visit 2) on 01/08/2025 with the Medical Social Worker (Personnel Record 8), the medication record at the group home lacked the Ativan. The group home caregiver stated that the Ativan was stopped when the Sertraline was started on 10/14/2024. The date of the last Registered Nurse Comprehensive Visit was 01/02/2025. The clinical record lacked documented evidence that the medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 3: The patient's date of election was 10/30/2024. The Medication Profile (Clinical Record 4) printed on 01/09/2025 revealed Tylenol 325mg tablet, two tablet oral every six hours as needed for pain/fever. During the home visit (Home Visit 3) ( on 01/09/2025 with the Licensed Practical Nurse (Personnel Record 7), the medication bottles revealed Tylenol 325mg tablet, two tablets every four hours as needed for pain/fever, last dispensed on 11/25/2024. The last Registered Nurse comprehensive assessment was dated 01/02/2025. The clinical record lacked documented evidence that medication reconciliation was completed and medications updated to the medication profile. During a joint record review and interview on 01/08/2025, the Director of Nursing (DON) confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile. The DON reported that the medication reconciliation occurs at the beginning of each month. The DON reported that the agency prints the medication record, which is signed by the medical director/associate medical director, and then provides it to the facility to reconcile with the facility list. The DON reported that finding a nurse/someone to compare medications or print a medication list for the agency to complete the medication reconciliation is often impossible. During a joint record review and interview on 01/09/2025, the Director of Nursing (DON) confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.

It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 9: The patient's date of election was 09/13/2023. The primary hospice diagnosis was Cerebrovascular disease, unspecified. The Registered Nurse Routine Nurse Visit note dated 12/19/2024 documented the patient having a seizure disorder and Type II Diabetes mellitus. The Medication Profile reviewed on 01/09/2025 revealed Lamotrigine 200mg twice a day for seizure activity effective 09/13/2023, Levetiracetam 500mg twice a day effective 05/17/2024, and Lantus 100 unit/ml 50ml twice a day for hyperglycemia. The Plan of Care effective 01/03/2025 lacked problems, interventions, and goals for risk for seizures, hypoglycemia, and hyperglycemia. CLINICAL RECORD 13: The patient's date of election was 01/23/2024. The primary hospice diagnosis was Atherosclerotic heart disease of the native coronary artery without angina pectoris. The skilled nursing note dated 01/24/2024 documented, "Discussed with Hospice team members and hospice medical director the need for change in the level of care to continuous care at home during this crisis related to pain and comfort medications medication administration with frequent changes and monitoring of patient." The record lacked care plan problems, interventions, and goals for the change in the level of care to continuous care. The patient expired on 01/26/2024. During a joint review of the record and an interview on 01/09/2025, the Administrator and Director of Nursing confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure that personnel followed the agency’s policy on hand hygiene. DOCUMENT 7: Agency Policy, "Hand Hygiene Policy and Compliance Program IC-5.7," effective January 2018, revised date July 1st, 2021, stated in part, "Indications for hand hygiene are: Before and after direct patient care. Before and after each procedure... After any contact with contaminated materials...Hospice will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: After removing gloves... After contact with blood, body fluids, mucous membranes, non-intact skin and wound dressings. Moving from contaminated patient body site to clean site during patient care." HOME VISIT 3: During the Home Visit (Home Visit 3) (Clinical Record 4) on 01/09/2025 with the Licensed Practical Nurse (LPN) (Personnel Record 7), the LPN was observed donning gloves, turning the patient to the side with the help of facility staff, and removing the pressure ulcer wound dressing. The LPN removed the gloves and donned a new pair. The LPN measured the wound, prepared the dressing supplies, and cleaned the wound. The LPN applied hydrogel to the wound and then changed the gloves. The LPN discovered a hole in one glove and changed the glove. The LPN was notified of a denuded skin area to the left of the pressure ulcer. The LPN cleaned the site with wound cleanser. The LPN placed calcium alginate on the pressure ulcer and covered both sites with a silicone supra-absorbent dressing. The LPN removed the gloves and used alcohol. The LPN was not observed to have cleaned the hands after removing each pair of gloves, after contact with wound dressings, and after contact with contaminated materials. During a joint document review and interview on 01/09/2025, the Administrator and Director of Nursing agreed the staff did not follow the hand hygiene policy.

It is required that a hospice aide provide services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. CLINICAL RECORD 13: The patient's date of admission was 01/23/2024. The Hospice Aide Plan of Care dated 01/23/2024 included "Bed bath every visit, Oral care every visit, Skin care (report changes to RN) every visit, Shave every visit, Shampoo every visit, Foot care (DO NOT TRIM TOENAILS, FILE ONLY) every visit, Nail care (Clean and file only) every visit, Dynashield as a barrier cream every visit, Change brief, change chux every visit, Incontinent care every visit, Diet as tolerated, Check durable medical equipment present/available every visit, Fall precautions every visit, Empty trash, Clean up room and bathroom after every visit, and Change linens every visit." The Hospice Aide visit note documented in narrative form dated 01/24/2024 at 11:01 PM documented, "Continuous care provided for this patient, changed brief, changed chux, oral care, bed bath." There was no documentation for "Skin care (report changes to RN) every visit, Shave every visit, Shampoo every visit, Foot care (DO NOT TRIM TOENAILS, FILE ONLY) every visit, Nail care (Clean and file only) every visit, Dynashield as a barrier cream every visit, Incontinent care every visit, Diet as tolerated, Check durable medical equipment present/available every visit, Fall precautions every visit, Empty trash, Clean up room and bathroom after every visit, and Change linens every visit." The Hospice Aide visit note documented in narrative form dated 01/25/2024 documented, "Continuous care provided for this patient, changed brief, changed chux, oral care, bed bath." There was no documentation for "Skin care (report changes to RN) every visit, Shave every visit, Shampoo every visit, Foot care (DO NOT TRIM TOENAILS, FILE ONLY) every visit, Nail care (Clean and file only) every visit, Dynashield as a barrier cream every visit, Incontinent care every visit, Diet as tolerated, Check durable medical equipment present/available every visit, Fall precautions every visit, Empty trash, Clean up room and bathroom after every visit, and Change linens every visit." The Hospice Aide visit note documented in narrative form dated 01/25/2024 documented, "continuous care visit change the patient brief mouth wash vital sign foot care mouth care reposition patient in bed nail care skin care change linen light cleaning change bed chap lotion change patient gown." There was no documentation for "Bed bath every visit, Skin care (report changes to RN) every visit, shave every visit, shampoo every visit, Dynashield as a barrier cream every visit, Incontinent care every visit, Diet as tolerated, check durable medical equipment present/available every visit, Fall precautions every visit, Empty trash." Vital sign, reposition patient in bed, lotion, and change patient gown were not on the Hospice Aide Plan of Care. During a joint review of the record and an interview on 01/08/2025, the Director of Nursing confirmed that the hospice aide did not provide services included in the hospice aide plan of care.

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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. CLINICAL RECORD 13: The patient's date of admission was 01/23/2024. The Hospice Aide Plan of Care dated 01/23/2024 included "Bed bath, Oral care, Skin care (report changes to RN),shave, shampoo, foot care (do not trim toenails, file only), nail care (Clean and file only), dynashield as a barrier cream, change brief, change chux ,incontinent care, diet as tolerated, check durable medical equipment present/available, fall precautions, empty trash, clean up room and bathroom, and change linens, every visit.” There was no documented evidence that the hospice Aide visit note dated 01/24/2024 included skin care, shave, shampoo, foot care, toenails (file only) nail care (clean and file only), dynashield as a barrier cream, incontinent care, diet as tolerated, check durable medical equipment present/available, fall precautions, empty trash, clean up room and bathroom, and change linens. There was no documented evidence that the hospice Aide visit note dated 01/24/2024 included skin care, shave, shampoo, foot care, nail care, dynashield as a barrier cream, incontinent care diet as tolerated, check durable medical equipment present/available, fall precautions, empty trash, clean up room, bathroom, and change linens, every visit. There was no documented evidence that the hospice Aide visit note dated 01/25/2024 included bed bath, skin care, shave, shampoo, dynashield as a barrier cream, incontinent care, diet as tolerated, check durable medical equipment present/available, fall precautions, and empty trash. The aide documented on 01/25/2024 that vital signs, reposition patient in bed, lotion, and change patient gown were completed however, these tasks were not on the Hospice Aide Plan of Care. There was no documented evidence that the aide notified the registered nurse of changes to the plan of care. During a joint clinical record review and interview on 01/08/2025, the Director of Nursing confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in the hospice aide plan of care.

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 described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. CLINICAL RECORD 12: The patient's care was transferred to another Hospice provider on 12/02/2024. There was no documented evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 01/09/2025, the Administrator and Director of Nursing confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation (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 clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 11: A review of the clinical record revealed the discharge summary dated 10/24/2024 did not include documented evidence that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 01/09/2025, the Administrator and Director of Nursing confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility.

It is required that a social worker has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education, or a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education, or a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above and at least one (1) year of social work experience in a health care setting or a baccalaureate degree from a school of social work accredited by the Council on Social Work Education and was employed by the hospice before December 2, 2008, is not required to be supervised by an MSW. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) personnel record for the MSW revealed that the agency did not ensure that the MSW met the agency’s job description for social worker. DOCUMENT 1: Agency Job Description: Job Title: Social Worker, not dated, stated in part, "Qualifications: Registration/licensure to practice as a Medical Social Worker in the state of practice." PERSONNEL RECORD 8: The date of hire was 02/15/2021. The MSW obtained a master's in social work on 07/13/1990. The record contained a competency for the MSW upon hire and an annual skills evaluation. The record lacks evidence of a license for a social worker in the state. During a joint personnel record review, document review, and interview on 01/08/20254, the Administrator confirmed that the record lacked a license for social work.

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. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by document review and interview. In 1 of 11 (9%) hospice contracts reviewed revealed that the agency did not ensure that the contract designated who would obtain the criminal background checks for employees who have direct patient contact or access to patient records. CONTRACT 2: The Hospice Medical Director contract dated 05/29/2024 lacked the designation of who would obtain criminal background checks for employees with direct patient contact or access to patient records. During a joint contract review and interview on 01/08/2025, the Administrator confirmed that the contract lacked the designation of who would obtain criminal background checks for employees with direct patient contact or access to patient records.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by interviews and clinical record review. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure an update of the comprehensive assessment was completed by the hospice Interdisciplinary Group (IDG) no less frequently than every 21 days as permitted under the Public Health Emergency. Record #89242: patient's diagnosis was Alzheimer's Disease with no documentation of a cancer diagnosis. The "IDG Comprehensive Reassessment" forms dated 2/2/22, 2/16/22 and 3/2/22 did not contain an update of the patient's comprehensive assessments including information on the patient’s progress toward desired outcomes, reassessment of the patient’s response to care and changes that had occurred since the initial assessment. The "IDG Comprehensive Reassessment" documentation included the incorrect age, diagnosis, and "cancerous lesions on abdomen and right shin," During the home visit, the patient was not observed to have lesions on her abdomen or shin. When interviewed, the office RN/Operations Manager stated he completed the "IDG Comprehensive Reassessment" forms since the IDG RN does not attend the IDG/IDT meetings. He did acknowledge that the IDG/IDT meeting notes dated 3/16/22 contained incorrect information. Record #47320: the patient was admitted to hospice with a stage 4 pressure ulcer. The "IDG Comprehensive Reassessment" forms dated 1/19/22, 2/2/22 and 2/16/22 included that the patient was "receiving wound care for stage 4." This form did not contain an update of the comprehensive reassessment including information on the patient’s progress towards desired outcomes, reassessment of the patient’s response to care, and wound changes that occurred since the initial assessment. Two RN nursing visits were performed on 2/15/22 and 3/5/22 with no reassessment of the stage 4 pressure ulcer. During home visit observation, the licensed practical nurse (LPN) confirmed that she performed weekly wound care and the caregiver stated that she provided wound dressing changes every three days and as needed when the dressing is soiled. Record #55270 was reviewed and revealed the "IDG Comprehensive Reassessment" forms dated 2/2/22 and 2/16/22 included "ulcers to BLE's are healing." There was no reassessment of the ulcers to the BLE's since the initial assessment. Review of the clinical record from 1/1/22 revealed two RN visits on 1/13/22 and 3/14/22 with no documentation of an assessment of the skin/ulcers. Documentation by the LPN for visits made on dated 2/1/22 and 2/8/22 and 2/14/22 did not include an assessment of the skin/ulcers. During home visit observation on 3/23/2022, the caregiver stated, “patient recently had scabs on left lower leg that opened up bleeding and I put a dressing on it two days ago." During interview, the office RN/Operations Manager stated "The RN who is assigned to visit the patient does not come to IDG meeting so I review the clinical record and interview staff to obtain information to complete the "IDG Comprehensive Assessment" form" and "sometimes I visit the patients." During interview the Administrator stated "we only have part time RNs who work 2 or more days a week who are assigned to visit the patients as needed", and "the RNs who are assigned to visit the patients do not attend IDG/IDT in person or by zoom since the RNs work part time and are not working on the day of IDG/IDT. The RN Operation Manager and Director of Nursing attend IDG". During interview the Director of Nursing confirmed that she attends IDG meeting and does make patient visits as needed.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by interview and clinical record review. 4 of 11 (27%) clinical records reviewed revealed the hospice did not ensure nursing visits followed the visit frequencies assigned in the plan of care and/or physician's orders. Record #70427 was reviewed and identified a physician's order for nursing visits dated 1/22/22 for two times a week, with no PRN visit frequency. Review of clinical record revealed one extra nursing visit on 1/29/22. Record #22541 was reviewed and identified a physician's order for nursing visits dated 2/14/22 for two times a week. Review of clinical record revealed one missing nursing visit the week of 2/14/22. Record #44573 was reviewed and identified a physician's order for nursing visits dated 2/3/22 for two times a week. Review of clinical record revealed one missing nursing visit the weeks of 2/3/22 and 2/6/22. Record #36909 was reviewed and identified a physician's order for nursing visits for two times a week. Review of clinical record revealed one missing nursing visit the weeks of 9/26/21 and 10/3/21. During clinical record review, the Medical Records Coordinator, acting at the direction of the administrator, stated she could not locate the missing nursing visits and/or physician's orders/plan of care for the extra nursing visit.

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 but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and 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 interview and clinical record review. 1 of 11 (9%) clinical records reviewed revealed the plan of care was not revised as frequency as the patient's condition requires but no less frequently than every 15 calendar days. Record #31526 was reviewed and identified the patient elected hospice care on 11/11/21. The clinical record included a COVID-19 positive lab results report dated 1/12/22. The plan of care was not updated and did not specify the hospice care and services necessary to meet the specific needs of the patient relating to the COVID-19 positive infection on 1/12/22. The "IDG Comprehensive Assessment" dated 1/19/22 included "COVID-19 test done 1/10/22" and did not include the positive results of the COVID-19 test. The plan of care dated 11/18/21 included "patient at risk for COVID". During clinical record review, the agency agreed that the plan of care was not revised to include care and services relating to the positive COVID-19 infection.

It is required that the hospice provides infection control education to patients, family members, and other caregivers that is individualized to the needs of each patient. This standard was not met as evidenced by interview and clinical record review. 1 of 2 (50%) applicable clinical record reviewed of patients with COVID-19 positive infection and/or COVID-19 person under investigation (PUI) revealed the hospice nurse failed to provide COVID-19 infection control training to the caregiver that was related to the care of the patient during the 1/10/22 nursing visit when the patient was placed under investigation for COVID-19 infection and when the positive COVID-19 test results were obtained on 1/12/22. Record #31526 was reviewed and identified the patient elected hospice care on 11/11/21. Documentation revealed the patient was short of breath on 1/10/22 and the LPN completed a nursing visit and performed the COVID-19 test. The positive COVID-19 test results report was documented on 1/12/22 with no documented follow up to the patient and caregiver regarding the positive COVID-19 test results. The clinical record review revealed no caregiver training and education on COVID-19 precautions or care of the patient until 1/17/2022, seven days after the patient was under investigation for COVID-19 infection and five days after the positive COVID-19 results report. During clinical record review, the Medical Records Coordinator stated that she reviewed the clinical record documentation and did not locate that the nurse educated the caregiver on COVID-19 infection control precautions and care of the patient until the LPN visit on 1/17/22. The LPN was not available for interview.

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 interview and clinical record review. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure the hospice aide was compliant with the ordered visit frequency. Record #22541 was reviewed and the physician's orders/plan of care contained the Hospice Aide visit frequency of two times a week. An extra hospice aide visit was documented the week of 2/20/22. During clinical record review, the Medical Records Coordinator, acting on behalf of the administrator confirmed the extra hospice aide visit note the week of 2/20/22. No physician's order was found to cover the extra hospice aide visit.

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, at a minimum physician orders. This standard was not met as evidenced by interview and clinical record review. 2 of 2 (100%) applicable records of patients receiving wound care revealed the hospice did not ensure accurate physician's orders were documented in the clinical record. Record #47320 was reviewed and identified inaccurate wound care order frequencies for dressing changes that were performed every three days and as needed. Physician's orders in the hospice clinical record dated 1/18/22 stated, "Sacral wound cleanse with NS, apply collagen pad, cover with dry dressing daily". During interview the caregiver stated, "I change the dressing every three days and as needed when soiled" and "I do not have a copy of the order here at the group home for dressing changes every three days". During home visit, the hospice LPN stated that she changes the wound dressing weekly and that the caregiver changes the dressing every three days and as needed when the dressing is soiled. During clinical record review, the Director of Nursing stated she was not aware that the dressing changes had changed from daily to every three days and obtained an updated verbal order on 3/24/22. Record #55270 was reviewed and identified the wound care order was missing the frequency to change the dressing. The clinical record revealed a physician's order dated 1/24/22 stated, "Right lower leg venous ulcer, cleanse with NS and/or wound cleanser, pat dry, apply therahoney or silvasorb or solosite hydrogel, followed by collagen pad, cover with dry dressing". The wound care order did not include the frequency of dressing changes. During interview, the caregiver at the assisted living facility stated "a scab opened up, with bleeding 2 days ago and I put a dressing on it. I will change the dressing every 3 days and as needed." The caregiver did not have a copy of the wound care orders. During clinical record review, the medical records coordinator, acting on behalf of the administrator confirmed the dressing change frequency was missing from the physician's order dated 1/24/22.