Every finding on record at Hospice of Hope-Tennessee, LLC

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 19 (5%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/29/2025 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the psychosocial assessment, completed as part of the initial comprehensive assessment, was completed by the Medical Social Worker (MSW) on 05/05/2025. A total of six days after the patient elected the hospice benefit and one day outstanding. During an interview on 05/22/2025, the MSW stated that she had miscounted the days and missed completing the psychosocial assessment within the 5-day window of the patient’s election to hospice care.

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 following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the individualized plan of care included complete orders for treatment necessary to meet the patient's needs. CLINICAL RECORD 6: The patient elected the hospice benefit on 04/23/2025 with a terminal diagnosis of malignant neoplasm of the lung. The Registered Nurse documented on the initial comprehensive assessment dated 04/23/2025 that the patient had a BiPap machine [ordered for breathing difficulties] with preset settings. The plan of care dated 04/23/2025 included an order for the BiPap machine. However, the order on the plan of care did not include the prescribed settings for the BiPap including the oxygen requirements, and the frequency/duration of use for the BiPap machine. During an interview and joint record review on 05/22/2025, the Administrator stated that the order should have included the settings required for the BiPap.

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, use of gloves, mask, eye protection, or face shield depending on anticipated exposure. safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 1 of 4 (25%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy CES 04-16 Infection Control-Hand Hygiene, required in part, "Hospice staff must wash hands... e. before and after wearing gloves…" HOME VISIT 3: During the home visit observation on 05/21/2025 with the Hospice Aide (HA) (Personnel Record 3), the HA was observed to remove gloves worn during care activities, place the discarded gloves into her uniform packet, and apply a new pair of gloves without first washing or sanitizing hands. During an interview and review of the home visit observation with the Administrator on 05/21/2025, the Administrator stated the aide had not followed the agency’s hand hygiene policy.

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient revocation and discharge, the agency did not ensure the hospice discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 15: The patient elected the hospice benefit 04/09/2024 with a terminal diagnosis of human immunodeficiency virus. The patient was discharged no longer terminally ill on 05/13/2025. There was no documented evidence in the clinical record that the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 16: The patient elected the hospice benefit 02/03/2025 with a terminal diagnosis of cerebral infarction. The patient revoked the hospice benefit on 04/26/2025. There was no documented evidence in the clinical record that the discharge summary was sent to the patient’s attending physician. During an interview and review of findings with the Administrator on 05/23/2025, there was an extensive search for documentation that the discharge summaries were sent to the receiving provider. The Administrator explained, the agency’s policy was to provide the discharge summary to the attending physician, but there was no evidence present in the clinical record, or the fax reports that the summaries had been sent to the providers. The Administrator stated that the agency had recently changed the EMR [electronic medical record] software, and it was noted at this time that the new EMR did not include a discharge summary process, and this was the determining factor as to why the discharge summary was not forwarded to the physician. The prior EMR had a discharge summary mechanism that was initiated electronically when a patient was discharged.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure the clinical record included documentation that the patient and/or caregiver(s) were instructed on the proper handling, storage, and safe utilization of durable medical equipment [DME] and supplies. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/29/2025 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the patient was ordered a hospital bed and mattress on 05/26/2025. The clinical record contained no documented evidence that the patient and/or caregiver was instructed on the proper handling, storage, and safe utilization of the DME equipment ordered for the patient. CLINICAL RECORD 10: The patient elected the hospice benefit on 05/15/2025 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the patient was ordered a hospital bed, oxygen concentrator, over the bed table, suction machine, nebulizer machine, two fall pads, an 18-inch gel cushion, and a high back wheelchair on 05/15/2025. The clinical record contained no documented evidence that the patient and/or caregiver was instructed on the proper handling, storage, and safe utilization of the DME equipment ordered for the patient. CLINICAL RECORD 13: The patient elected the hospice benefit on 04/09/2025 with a terminal diagnosis of Parkinson's Disease. Clinical record review revealed the patient was ordered a hospital bed, oxygen concentrator, 2 fall mats, nebulizer machine, and a wheelchair on 04/09/2025. The clinical record contained no documented evidence that the patient and/or caregiver was instructed on the proper handling, storage, and safe utilization of the DME equipment ordered for the patient. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/07/2024 with a terminal diagnosis of cerebral infarction. Clinical record review revealed the patient was ordered a bedside commode, oxygen concentrator, over the bed table, suction machine, nebulizer machine, shower chair, and e-tanks on 09/24/2024. The clinical record contained no documented evidence that the patient and/or caregiver was instructed on the proper handling, storage, and safe utilization of the DME equipment ordered for the patient. During an interview and joint review of records on 05/23/2025, the Administrator stated there was no documentation in the clinical records of DME education provided to the patient, the family, or caregivers. She explained that the new EMR [electronic medical record] did not have a designated section in the comprehensive assessment or plan of care to document this education, so the nurses were not prompted to document the training in the clinical record.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1 (100%) clinical record reviewed in which a patient resided in a Skilled Nursing Facility (SNF), the agency did not ensure the hospice plan of care identified the care and services needed and specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit 02/17/2025 with a terminal diagnosis of atherosclerotic heart disease. The patient resided in a SNF. Clinical record review revealed a wound care order was written on 05/15/2025 to cleanse wound with wound cleaner, pat dry, apply calcium alginate and cover with dressing. The hospice plan of care did not include documentation of which provider was responsible to provide the wound care. During the home visit observation on 05/20/2025 with the Medical Social Worker (MSW) (Personnel Record 2), the hospice binder at the facility was reviewed. There was no documentation in the binder that identified which provider was responsible for the wound care ordered for the patient. During an interview on 05/24/2025, the Case Manager stated that the wound care was being provided by the facility. The Hospice Aide or the Hospice Nurse would notify the facility Wound Care Nurse when the bath was being performed and the facility Wound Care Nurse would perform the wound care during that time. The clinical record included documentation that hospice staff had observed the wound care provided by the facility nurse, but the plan of care did not include the delineation of duties related to the wound care order. During an interview on 05/20/2025, the Administrator stated that the plan of care did not identify the provider that was responsible for the wound care.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care and physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1 (100%) clinical record reviewed in which a patient resided in a Skilled Nursing Facility (SNF), the agency did not ensure the most recent hospice plan of care, and the physician certification of the terminal illness was provided to the facility. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit 02/17/2025 with a terminal diagnosis of atherosclerotic heart disease. The patient resided in a SNF. During the home visit observation on 05/20/2025 with the Medical Social Worker (MSW) (Personnel Record 2), the hospice binder at the facility was reviewed. There was no documented evidence in the binder to verify that the SNF had been provided with the most recent hospice plan of care and physician certification of terminal illness. During an interview on 05/20/2025, the Administrator stated the facility binder should have included a copy of the patient’s most recent hospice plan of care and physician certification of terminal illness for the patient.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by clinical record review and staff interview. 4 of 11 (36%) clinical records reviewed revealed the agency did not ensure that the plan of care addressed the specific needs of the patients. Record #96914 (Election of benefit 1/9/2022): In the initial nursing assessment, on 1/9/2022, the RN documented that the patient had a colostomy. The current care plan, effective as of 1/9/22, does not include any goals or interventions related to the gastrointestinal system or the colostomy. Record #28557 (Election of benefit 3/31/2022): In the initial nursing assessment, on 3/31/22, the RN documented that the patient was experiencing "constant bone pain." The current care plan, effective as of 3/31/22, did not address pain or pain management. Record # 97644 (Election of benefit 3/02/2022): A physician order, dated 3/3/22, stated, "place Foley catheter for urinary retention." In a face-to-face visit on 5/4/22, the Nurse Practitioner, documented that the Foley catheter was still in place. The current plan of care, effective as of 3/2/22, did not include any problems, goals or interventions related to the genitourinary system or the Foley catheter. Record # 10950 (Election of benefit 3/22/2022): In the initial nursing assessment, on 3/22/22, the RN documented that the patient had a Percutaneous Endoscopic Gastrostomy (PEG) tube and listed tube feedings for the diet/nutritional intake. The current care plan, effective as of 3/22/22 did not address any goals or interventions related to nutritional status, tube feedings or the PEG tube. The Director of Nursing (#14727) was interviewed on 5/11/2022 and she confirmed that the care plan for these patients did not include the goals and interventions to meet the specific needs identified in the nursing assessments.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and staff interview. 1 of 1 (100%) clinical records reviewed revealed the agency did not ensure that the plan of care for a patient residing in a skilled nursing facility (SNF) specified which provider was responsible for performing specific functions. Patient (record #48978, election of benefit 11/14/21) was documented as residing in a skilled nursing facility during the course of the hospice service period. The plan of care (effective date 11/14/2021) did not delineate which provider was responsible for the specific functions. The Director of Nursing (#14727) was interviewed on 5/12/2022 and reported that the electronic medical record does not contain an area where they can identify which provider is responsible for which task. The agency had not developed any other process to meet this requirement.

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 document review and interview. 2 of 7 (29%) contracts reviewed revealed that the hospice did not ensure the contracts contained the requirement for the contracted organization to obtain criminal background checks on all their employees who have direct patient contact or access to the patient records. The contract for the Medical Director #83139 (effective date: 12/01/2021) and the contract for hospice physician #62075 (effective date: 6/01/2021) did not contain regulatory language requiring the criminal background checks. In an interview with Chief Operations Officer (COO), conducted on May 11, 2022, she confirmed that the contracts for physicians did not contain language requiring criminal background checks. She reported that the agency verified the physician licensure and DEA (Drug Enforcement Administration) numbers, and checked the OIG (Office of the Inspector General) exclusion list so she thought that was all they needed in regards to the contracted physicians.