Every finding on record at Hospice Services of Lake County

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure the registered nurse (RN) completed visits as per the frequency ordered on the interdisciplinary group (IDG) plan of care (POC). CLINICAL RECORD 1: The IDG POC dated 01/31/2025 for the certification dates of 01/31/2025 - 04/30/2025, ordered the RN frequency to be one (1) visit every (2) two weeks. The record had evidence that the RN completed a visit on 02/27/2025. A subsequent RN visit was made on 03/17/2025 (Day 18). The record lacked supportive documentation as to why the RN visit was late. The Executive Director/Administrator and Director of Patient Care Services stated in an interview on 04/18/2025 that the agency did not ensure the RN completed visits as per the frequency ordered on the IDG POC. Prior to SV leaving the site, the DPCS reported that this issue has been addressed with a change in process that started on 04/01/2025.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) % clinical records reviewed for patients that elected aide services revealed the agency did not ensure the hospice aide provided services included in the aide care plan. CLINICAL RECORD 2: The aide care plan dated 03/20/2025 had a task ordered for "Oral Care". The aide had a visit frequency order for two (2) times a week. The aide visit notes dated 03/19/2025 and 03/27/2025 lacked evidence that the aide performed the task "Oral Care" as ordered. The record lacked evidence of supportive documentation as to why the "Oral Care" was not performed. The Executive Director/Administrator and Director of Patient Care Services stated in an interview on 08/02/2024 that the agency did not ensure the hospice aide provided services included in the aide care plan.

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 2 of 4 (50%) records reviewed in which the patient elected hospice aide services and required the aide to notify the registered nurse (RN) revealed the agency did not ensure the hospice aide reported changes in the patient's medical needs to the RN as the changes related to the plan of care (POC). CLINICAL RECORD 2: The aide care plan dated 03/20/2025 had a task ordered "Oral Care". The aide had a visit frequency order for two (2) times a week. The aide visit notes dated 03/19/2025 and 03/27/2025 lacked evidence that the aide performed the task of "Oral Care" as ordered. The record lacked evidence of supportive documentation as to why the "Oral Care" was not "Performed". The record lacked evidence that the aide reported changes in the patient's medical needs to the RN as related to the "Oral Care" task ordered. CLINICAL RECORD 3: The aide care plan dated 04/03/2025 had a task ordered "Oral Care". The aide had a visit frequency order for two (2) times a week. The aide visit note dated 04/15/2025 lacked evidence that the aide performed the task of "Oral Care" as ordered. The record had supportive documentation that stated the patient refused the "Oral Care". The record lacked evidence that the aide reported changes in the patient's medical needs to the RN as related to the "Oral Care" task ordered and patient refusing. The Executive Director/Administrator and Director of Patient Care Services stated in an interview on 04/18/2025 that the agency did not ensure the hospice aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed with hospice aide services provided, the agency did not ensure the registered nurse (RN) made an on-site aide supervisory visits no less frequently than every 14 days. CLINICAL RECORD 1: The aide care plan dated 01/31/2025 (Certification dates: 01/31/2025 - 04/20/2025) ordered the aide to visit the patient two (2) times per week. The aide supervisory visit dated 03/28/2025 was the last aide supervisory visit documented. The record lacked evidence of the RN supervisory visit being completed as of 04/17/2024 (six (6) days late), with no supportive documentation as to the reason. CLINICAL RECORD 2: The aide care plan dated 02/24/2025 (Certification dates: 02/24/2024 - 04/24/2025) ordered the aide to visit the patient two (2) times per week. The aide supervisory visit dated 03/27/2025 was the last aide supervisory visit documented. The record lacked evidence of the RN supervisory visit being completed as of 04/17/2024 (seven (7) days late), with no supportive documentation as to the reason. The Executive Director/Administrator and Director of Patient Care Services stated in an interview on 04/18/2025 that the agency did not ensure the RN made an on-site aide supervisory visit no less frequently than every 14 days. Per the DPCS, this process was already a work in progress prior to the end of this site visit.

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. This standard was not met as evidenced by document review and interview. In 2 of 2 (100%) home visit observations, the organization did not ensure the patient was provided with written information related to state-specific advanced directive information. Home Visit 1: During the home visit observation on 10/28/2024 with the Medical Social Worker (Personnel Record 1), a review of the patient's handbook revealed no documented evidence that the patient was provided with state-specific advanced directive information. Home Visit 2: During the home visit observation on 10/29/2024 with the Registered Nurse (Personnel Record 2), a review of the patient's handbook revealed no documented evidence that the patient was provided with state-specific advanced directive information. During an interview and review of findings on 10/28/2024, the Executive Director confirmed that patient handbooks distributed to patients at the initiation of hospice services did not include state-specific advanced directive information.

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 2 (50%) clinical records reviewed for start of care, the organization did not ensure the hospice Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five calendar days after the election of hospice care. Clinical Record 4: The patient elected the hospice benefit on 08/05/2024 with terminal diagnosis of protein-calorie malnutrition. Clinical record review revealed the Spiritual Counselor, as a member of the IDG, did not document a spiritual assessment as part of the initial comprehensive assessment during the five calendar days after the patient’s election of hospice care. During an interview and record review on 10/29/2024, the Director of Operations confirmed the record did not include an initial spiritual assessment completed by the spiritual counselor. The Director of Operations stated that there was no documentation in the patient's clinical record indicating that the patient refused spiritual counseling services or that the physician was notified or approved of a missed visit by the spiritual counselor.

It is required that the hospice designates a Registered Nurse [RN] member of the IDG [interdisciplinary group] to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, the hospice did not ensure hospice care and services were provided in accordance with the plan of care. Clinical Record 1: The patient elected the hospice benefit on 11/22/2023 with terminal diagnosis of malignant neoplasm of the right breast with metastasis to the bones and cerebral meninges. Clinical record review revealed the Spiritual Counselor documented visits to the patient on 09/20/2024, 10/12/2024, 10/18/2024, and 10/25/2024. There was no documented evidence in the clinical record that Spiritual Counseling services had been ordered for the patient for the benefit period dated 09/17/2024 to 11/15/2024. During an interview and record review on 10/29/2024, the Director of Operations stated, "The last physician's orders for a spiritual counselor ended on 05/19/2024. There were no physician's orders [in the clinical record] for the spiritual counselor visits." Clinical Record 5: The patient elected the hospice benefit on 05/15/2023 with terminal diagnosis of senile degeneration of the brain. The documented date of death was 08/04/2024. The clinical record included a physician order to increase nursing frequency of visits to daily effective 07/31/2024. Review of the clinical record revealed there was no documented evidence that nursing provided a visit to the patient on 08/03/2024, the day before the patient’s death and there was no documented evidence of a missed visit. During an interview and record review on 10/29/2024, the Director of Operations stated, "It looks like we missed the nursing visit on that day and did not document why the visit was missed."

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, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, the organization did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 11/22/2023 with terminal diagnoses of malignant neoplasm of the right breast with metastasis to the bones. The plan of care dated 09/17/2024 to 11/15/2024 and the update to the plan of care dated 10/24/2024 included a mobility goal for the patient that documented, "Patient will maintain optimal (DEFINE) mobility by 12/31/2024." The goal was not measurable when it did not define or describe what optimal mobility would be for the patient. During an interview and record review on 10/29/2024, the Director of Operations stated, "The clinician is supposed to define what optimal mobility means. The outcomes should be patient-specific and measurable, but this one was not updated." Clinical Record 2: The patient elected the hospice benefit on 10/04/2024 with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care dated 10/04/2024 and the update to the plan of care dated 10/24/2024 included a mobility goal for the patient that documented, "Patient will maintain optimal (DEFINE) mobility by 12/31/2024." The goal was not measurable when it did not define or describe what optimal mobility would be for the patient. During an interview and record review on 10/29/2024, the Director of Operations stated, "The clinician is supposed to define what optimal mobility means. The outcomes should be patient-specific and measurable, but this one was not updated."

It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document review and interview. The organization did not ensure adverse events were tracked and analyzed and preventative actions were implemented. During the entrance conference on 10/28/2024, the organization’s Executive Director was asked to provide the organization's complaint policy and documentation of complaints /complaint investigations that have occurred since the last deemed renewal site visit on 01/12/2024. On 10/28/2024 the Executive Director provided a policy titled Compliant/Grievance Process, last reviewed 03/19/2021, that stated in part, "all complaints will be logged, tracked, trended, and filed in the Human Resources Office. The Administrative Team will review patient grievance trends on a quarterly basis. Identified trends will be followed through the established performance improvement process." The Executive Director stated, "if there is any complaint documentation [for the agency] it is locked up in the computer of the Director of Patient Care Service, who is currently on medical leave." On 10/29/2024 the Director of Operations provided another policy titled Compliant/Grievance Process, with a revision date of 11/2023, that stated in part, "The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Bills of Rights Document given to each patient upon admission. The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. Complaints and any action taken will be documented on a complaint form. All complaints will be logged, tracked, trended, and filed in the performance improvement office. The Performance Improvement Coordinator will prepare a quarterly report summarizing all complaints received that quarter. ...The Performance Improvement Committee will review patient grievance trends on a quarterly basis." The Director of Operations also provided a document titled "Complaint Log" that included documentation that the last complaint entered was dated 06/22/2021. The Executive Director stated, "We were not able to find any complaints documented other than these back in 2021. The Quality Nurse confirmed that complaints were not tracked, trended, or analyzed as a part of the organization's QAPI [Quality Assessment Performance Improvement] program." The organization did not ensure that performance improvement activities were tracked, analyzed, or implemented preventative action and mechanisms related to complaints or grievances from patients or families as required by organizational policy.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group, included in the plan of care, and permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide provided services as ordered by the Interdisciplinary Group (IDG) in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 10/04/2024. Aide services were ordered by the IDG twice a week, effective 10/07/2024. The aide documented on the aide visit notes dated 10/15/2024 and 10/24/2024 that the patient refused personal care services. During an interview and clinical record review on 10/29/2024, the Director of Operations stated that the two aide visits were missed visits but had been documented as visits performed.

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 1 of 3 (33%) clinical records reviewed with aide services provided, the organization did not ensure the Hospice Aide reported changes in patient's needs to the Registered Nurse. Clinical Record 2: The patient elected the hospice benefit on 10/04/2024. Aide services were ordered twice a week, effective 10/07/2024. The aide plan of care assigned the aide to provide the patient with a shower at each visit. The Hospice Aide documented on the aide visit note dated 10/17/2024 that the patient was “too weak for a shower [and] requested a bed bath." During an interview and clinical record review on 10/29/2024, the Director of Operations confirmed the documentation showed the aide did not perform services as ordered on the aide plan of care and there was no documentation in the clinical record that the aide notified the Registered Nurse of the changes in the patient’s condition.

It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review and interview. The organization did not ensure the governing body assumed full legal authority and responsibility for the organization's ongoing performance improvement and patient safety program related to tracking and trending of patient complaints /grievances and potential adverse events. During the entrance conference on 10/28/2024, the organization’s Executive Director was asked to provide the organization's complaint policy and documentation of complaints /complaint investigations that have occurred since the last deemed renewal site visit on 01/12/2024. On 10/28/2024 the Executive Director provided a policy titled Compliant/Grievance Process, last reviewed 03/19/2021, that stated in part, "all complaints will be logged, tracked, trended, and filed in the Human Resources Office. The Administrative Team will review patient grievance trends on a quarterly basis. Identified trends will be followed through the established performance improvement process." The Executive Director stated, "if there is any complaint documentation [for the agency] it is locked up in the computer of the Director of Patient Care Service, who is currently on medical leave." On 10/29/2024 the Director of Operations provided another policy titled Compliant/Grievance Process, with a revision date of 11/2023, that stated in part, "The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Bills of Rights Document given to each patient upon admission. The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. Complaints and any action taken will be documented on a complaint form. All complaints will be logged, tracked, trended, and filed in the performance improvement office. The Performance Improvement Coordinator will prepare a quarterly report summarizing all complaints received that quarter. ...The Performance Improvement Committee will review patient grievance trends on a quarterly basis." The Director of Operations also provided a document titled "Complaint Log" that included documentation that the last complaint entered was dated 06/22/2021. The Executive Director stated, "We were not able to find any complaints documented other than these back in 2021. The Quality Nurse confirmed that complaints were not tracked, trended, or analyzed as a part of the organization's QAPI [Quality Assessment Performance Improvement] program." The governing body did not ensure patient complaints and/or grievances were documented and investigated as part of the organization’s performance improvement and patient safety program. The governing body did not ensure that the organization's ongoing performance improvement and patient safety program related to patient and family complaints and grievances was implemented and evaluated as required by organizational policy.

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 2 of 4 (50%) personnel records reviewed, the organization did not ensure employees were provided with an initial orientation that addressed the employee’s job specific duties. Personnel Record 2: Registered Nurse (RN) date of hire 07/23/2024. Personnel record review revealed no documented evidence that the nurse participated in the organization’s new hire orientation, as of the date of record review on 10/29/2024. During an interview and personnel record review on 10/29/2024, the Human Resources Director stated, "The RN was onboarded when the previous Director of Patient Care Services [DPCS], who is on medical leave, was responsible for orientation. The RN's orientation was not done, but I am going to see that it gets completed as soon as possible." Personnel Record 4: Medical Social Worker with Bachelor of Social Work date of hire 07/01/2024. Personnel record review revealed no documented evidence that the Social Worker participated in the organization’s new hire orientation, as of the date of record review on 10/29/2024. During an interview and personnel record review on 10/29/2024, the Human Resources Director stated, "The social worker was another associate onboarded when the previous DPCS was responsible for orientation. The Social Worker's orientation was not done, but I am going to see that it gets completed as soon as possible."

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. This standard was not met as evidenced by personnel record review and interview. In 2 of 4 (50%) personnel records reviewed, the organization did not ensure the skills and competencies of clinical staff were assessed. Personnel Record 2: Registered Nurse (RN) date of hire 07/23/2024. Personnel record review revealed no documented evidence that a competency evaluation was completed for the RN, as of the date of record review on 10/29/2024. During an interview and personnel record review on 10/29/2024, the Human Resources Director stated, "The RN was onboarded when the previous Director of Patient Care Services [DPCS], who is on medical leave, was responsible for responsible for observing and validating competencies and skills. The RN's competency assessment was not documented, but I am going to see that it gets completed as soon as possible." Personnel Record 4: Medical Social Worker with Bachelor of Social Work date of hire 07/01/2024. Personnel record review revealed no documented evidence that a competency evaluation was completed for the Social Worker, as of the date of record review on 10/29/2024. During an interview and personnel record review on 10/29/2024, the Human Resources Director stated, "The Social Worker was another associate onboarded when the previous DPCS was responsible for ensuring that competency assessments were completed and documented. The Social Worker's competency assessment was not documented, but I am going to see that it gets completed as soon as possible."

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 for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed with patient recertification of hospice care, the organization did not ensure recertification for the hospice care benefit included documentation of the Medical Director’s review of the patient’s clinical information. Clinical Record 3: The patient elected the hospice benefit on 07/20/2023 with a terminal diagnosis of unspecified severe dementia. The patient’s date of death was documented as 08/11/2024. Clinical record review revealed the Physician’s Recertification of Terminal Illness form dated 07/22/2024 for the benefit period dated 07/14/2024 to 09/11/2024 was incomplete and did not include a physician narrative and signature. The form included the statement "By applying my signature, I attest and confirm that I composed the above narrative based on my review of the patient's medical record, and if applicable, examination of the patient." During an interview and record review on 10/29/2024, the Director of Operations confirmed that there was no physician signature on the form, so there was no confirmation that the physician had reviewed the patient’s clinical information. Clinical Record 5: The patient elected the hospice benefit on 05/15/2023 with a terminal diagnosis of senile degeneration of the brain. The patient’s date of death was documented as 08/11/2024. Clinical record review revealed the Physician’s Recertification of Terminal Illness forms for the benefit periods dated 05/09/2024 to 07/07/2024 and 07/08/2024 to 09/05/2024 were incomplete and did not include a physician narrative and signature. The forms included the statement "By applying my signature, I attest and confirm that I composed the above narrative based on my review of the patient's medical record, and if applicable, examination of the patient." During an interview and record review on 10/29/2024, the Director of Operations confirmed that there was no physician signature on the forms, so there was no confirmation that the physician had reviewed the patient’s clinical information. Clinical Record 6: The patient elected the hospice benefit on 03/28/2024 with a terminal diagnosis of end-stage renal disease. The patient was a live discharge on 10/04/2024 for extended prognosis. Clinical record review revealed the Physician’s Recertification of Terminal Illness form for the benefit period dated 09/24/2024 to 11/22/2024 was incomplete and did not include a physician narrative and signature. The form included the statement "By applying my signature, I attest and confirm that I composed the above narrative based on my review of the patient's medical record, and if applicable, examination of the patient." During an interview and record review on 10/29/2024, the Director of Operations confirmed that there was no physician signature on the form, so there was no confirmation that the physician had reviewed the patient’s clinical information.

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 3 of 4 (75%) clinical records reviewed with patient recertification of hospice care, the organization did not ensure recertification of hospice care was 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. Clinical Record 3: The patient elected the hospice benefit on 07/20/2023 with a terminal diagnosis of unspecified severe dementia. The patient’s date of death was documented as 08/11/2024. Clinical record review revealed the Physician’s Recertification of Terminal Illness form dated 07/22/2024 for the benefit period dated 07/14/2024 to 09/11/2024 was incomplete. The form was left blank in the following fields: diagnoses (primary and secondary), verbal certification, hospice physician narrative summary certification, and attestation. During an interview and record review on 10/29/2024, the Director of Operations confirmed that there was no physician signature on the form, so there was no confirmation by the physician for the statements "I certify that this individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course" and "By applying my signature, I attest and confirm that I composed the above narrative based on my review of the patient's medical record, and if applicable, examination of the patient." The Director of Operations stated, "the recertification of terminal illness was not completed [when it did not include the physician’s signature]." Clinical Record 5: The patient elected the hospice benefit on 05/15/2023 with a terminal diagnosis of senile degeneration of the brain. The patient’s date of death was documented as 08/04/2024. Clinical record review revealed the Physician’s Recertification of Terminal Illness form for the benefit period 05/09/2024 to 07/072024 and the Physician’s Recertification of Terminal Illness form for the benefit period dated 07/08/2024 to 09/05/2024 were left blank and not completed by the physician. During an interview and record review on 10/29/2024, the Director of Operations confirmed the Hospice Medical Director did not provide written and signed recertification of terminal illness when the forms were left blank. Clinical Record 6: The patient elected the hospice benefit on 03/28/2024 with a terminal diagnosis of end-stage renal disease. The patient was a live discharge on 10/04/2024 for extended prognosis. Clinical record review revealed the Physician’s Recertification of Terminal Illness form for the benefit period 09/24/2024 to 11/22/2024 was left blank and not completed by the physician. During an interview and record review on 10/29/2024, the Director of Operations confirmed the Hospice Medical Director did not provide written and signed recertification of terminal illness when the form was left blank.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, physician's orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, the organization did not ensure the clinical record included physician's orders. Clinical Record 1: The patient was admitted to hospice services on 11/22/2023 with terminal diagnosis of malignant neoplasm of the right breast with metastasis to the bones and cerebral meninges. Clinical record review revealed the Spiritual Counselor documented visits to the patient on 09/20/2024, 10/12/2024, 10/18/2024, and 10/25/2024. There was no documented evidence in the clinical record that Spiritual Counseling services had been ordered for the patient for the benefit period dated 09/17/2024 to 11/15/2024. During an interview and record review on 10/29/2024, the Director of Operations stated, "The last physician's orders for a spiritual counselor ended on 05/19/2024. There were no physician's orders [in the clinical record] for the spiritual counselor visits."

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. Review of the Emergency Preparedness (EP) binder, provided by the Director of Development revealed no documented evidence of a hospice based and community-based risk assessment, using an “all-hazards” approach specific to the geographical area and population served by the hospice. During a joint review of the EP binder on 01/11/2024, the Director of Development and the Director of Patient Care Services acknowledged that the risk assessment was missing and stated they were waiting on the county to provide them with the information.

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. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that an initial bereavement assessment was included in the comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023, with a terminal diagnosis of malignant neoplasm of the frontal lobe. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 8: The patient elected the hospice benefit on 11/30/2023, with a terminal diagnosis of nontraumatic chronic subdural hemorrhage. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 11: The patient elected the hospice benefit on 11/22/2023, with a terminal diagnosis of malignant neoplasm of the female breast. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. During a daily wrap up meeting on 01/11/2024, the Director of Patient Care Services, Nurse Practitioner, Director of Finance and Human Resources, and Bereavement Coordinator acknowledged that there was some recent confusion and discussions related to the initial bereavement assessment and agreed these records were missing an initial bereavement assessment.

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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 12 of 19 (63%) clinical records reviewed, the organization did not ensure the individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the POC. Clinical Record 1: The patient elected the hospice benefit on 04/26/2023, with a terminal diagnosis of sarcopenia. The POC dated 04/26/2023 included a patient care management goal that stated, "Optimal strength, mobility and independence" and a nutrition goal that stated, "Optimal nutritional status and patient comfort." The goals were not measurable when they did not describe what optimal strength and optimal nutritional status would be for the patient. Clinical Record 5: The patient elected the hospice benefit on 09/20/2023, with a terminal diagnosis of senile degeneration of the brain. The POC dated 12/19/2023 included a safety/environmental goal that stated, "optimal patient/caregiver safety." The goal was not measurable when it did not include a description or definition of what optimal safety would be for the patient/caregiver. Clinical Record 6: The patient elected the hospice benefit on 10/04/2023, with a terminal diagnosis of chronic systolic congestive heart failure. The POC dated 10/04/2023 included a safety/environmental goal that stated, "Optimal caregiver(s) knowledge/performance in patient care." The goal was not measurable when it did not define what optimal knowledge/performance would be for the caregiver. Clinical Record 7: The patient elected the hospice benefit on 07/14/2023, with a terminal diagnosis of dementia and severe agitation. The POC dated 12/08/2023 included an elimination goal that stated, "Optimal urinary elimination patterns and comfort." The goal was not measurable when it did not define what optimal elimination patterns or comfort would be for the patient. Clinical Record 10: The patient elected the hospice benefit on 12/28/2023, with a terminal diagnosis of malignant neoplasm of the female breast. The POC dated 12/28/2023 included a nutritional goal that stated, "Optimal nutritional status and patient comfort." The goal was not measurable when it did not define what optimal nutritional status would be for the patient. Clinical Record 12: The patient elected the hospice benefit on 12/12/2023, with a terminal diagnosis of liver cell carcinoma. The POC dated 12/20/2023 included a nutritional goal that stated, "Optimal nutritional status and patient comfort." The goal was not measurable when it did not define what optimal nutritional status was for the patient. Clinical Record 13: The patient elected the hospice benefit on 10/03/2023, with a terminal diagnosis of cerebral infarction. The POC dated 12/27/2023 included goals for elimination that stated, "Optimal bowel elimination status and patient comfort” and “Optimal urinary elimination patterns and comfort." The goals were not measurable when they did not describe or define what optimal bowel elimination and urinary elimination would be for the patient. Clinical Record 15: The patient elected hospice benefit on 01/09/2023, with a terminal diagnosis of severe protein calorie malnutrition. The POC dated 01/09/2023 included goals for elimination that stated, "Optimal bowel elimination status and patient comfort” and “Optimal urinary elimination patterns." The goals were not measurable when they did not describe or define what optimal bowel elimination and urinary elimination would be for the patient. Clinical Record 16: The patient elected hospice benefit on 06/28/2023, with a terminal diagnosis of malignant neoplasm of pelvic bones, sacrum, and coccyx. The POC dated 06/28/2023 included an elimination goal that stated, "optimal elimination patterns and comfort." The goal was not measurable when it did not define what optimal elimination patterns would be for the patient. Clinical Record 17: The patient elected hospice benefit on 12/19/2022, with a terminal diagnosis of severe protein calorie malnutrition. The POC dated 12/19/2022 included an elimination goal that stated, "optimal elimination patterns and comfort." The goal was not measurable when it did not describe or define what an optimal elimination pattern would be for the patient. Clinical Record 18: The patient elected hospice benefit on 04/05/2023, with a terminal diagnosis of intracranial lesion found on diagnostic imaging. The POC dated 04/17/2023 included goals for elimination that stated, "Optimal bowel elimination status and patient comfort” and “Optimal urinary elimination patterns." The goals were not measurable when they did not describe or define what optimal bowel elimination and urinary elimination would be for the patient. Clinical Record 19: The patient elected hospice benefit on 08/19/2023, with a terminal diagnosis of malignant neoplasm of bronchus and lung. The POC dated 08/19/2022 included a goal for self-care deficit that stated, "Patient will maintain optimal activity level as permitted by disease process." The goal was not measurable when it did not describe or define what optimal activity would be for the patient. During a daily wrap up meeting and record review on 01/11/2024, the Director of Patient Care Services, Nurse Practitioner, Director of Finance and Human Resources, and Bereavement Coordinator acknowledged that the identified POC goals were non-measurable.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, personnel record review, and interview. In 2 of 10 (20%) personnel records reviewed, the agency did not ensure attendance and documentation of infection control education provided to staff as required by agency policy. Agency policy Infection Control Plan, reviewed 9/1/2020, stated in part, "Infection control in-services will be scheduled no less than annually. Attendance will be mandatory and documented. Records of in-service attendance will be maintained in the personnel file." Personnel Record 4: Social Worker date of hire 08/09/2021. Personnel record review revealed no documented evidence of infection control education for 2022 and 2023. Personnel Record 5: Bereavement Manager date of hire 04/20/2013. Personnel record review revealed no documented evidence of infection control education for 2022. During a joint personnel file review on 01/11/2024 with the Director of Finance and Human Resources it was reviewed and confirmed that the files showed no evidence of infection control education being completed.

It is required that a hospice located in a non-urbanized area may submit a written request for a waiver of the requirement for providing physical therapy, occupational therapy, speech-language pathology, and dietary counseling services. This standard was not met as evidenced by document review and interview. Code of Federal Regulations (CFR) 418.74(a)(2)(c) stated, "If a hospice wishes to receive a 1-year extension, it must submit a request to CMS [Centers for Medicare and Medicaid Services] before the expiration of the waiver period and certify that conditions under which it originally requested the waiver have not changed since the initial waiver was granted." Review of the agency's previous waiver request revealed it was dated 05/22/2022. A letter from CMS dated 06/07/2022 approved the request and stated in part, "The waiver will remain in effect for 1 year from the date of the request." During an interview with the Director of Development on 01/11/2024, the waiver was reviewed and acknowledged that the previous waiver had expired before the agency had requested a new waiver on 12/01/2023.

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. In 1 of 9 (11%) clinical records reviewed of patients receiving aide services, the agency did not ensure the Registered Nurse (RN) prepared patient specific written patient care instructions for the hospice aide. Clinical Record 8: The patient elected the hospice benefit on 11/30/2023, with a terminal diagnosis of nontraumatic chronic subdural hemorrhage. The aide plan of care assignment completed by the RN and dated 12/18/2023 assigned the aide the task "Provide complete bed bath or shower of entire body." The aide plan of care assignment did not include patient specific tasks for the type of bath when it included a bed bath and shower. During a daily wrap up conference with the Director of Patient Care Services, Nurse Practitioner, and Director of Finance and Human Resources on 01/10/2024, it was discussed and acknowledged that the aide plan of care was generic and not patient specific.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed with hospice aide services provided, the agency did not ensure a Registered Nurse made an on-site supervisory visit no less frequently than every 14 days. Clinical Record 8: The patient elected the hospice benefit on 11/30/2023, with a terminal diagnosis of nontraumatic chronic subdural hemorrhage. A physician order dated 12/18/2023 ordered hospice aide services twice a week and the Registered Nurse developed the hospice aide plan of care on the same date. Hospice aide visits began on 12/19/2023. Clinical record review revealed no documented evidence, that an aide supervisory visit was completed as of the date of clinical record review on 01/11/2023, 23 days after the start of aide services and 9 days outstanding. During a daily wrap up meeting with the Director of Patient Care Services, Nurse Practitioner, Director of Finance and Human Resources, and Bereavement Coordinator on 01/11/2024 it was reviewed and acknowledged that the identified clinical record was missing an aide supervisory visit by a Registered Nurse.

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. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 9 (11%) personnel records reviewed for clinicians providing direct patient care, the agency did not ensure assessment and documentation of the direct care clinician’s skills and competencies. Agency policy Clinical Competency Assessments, reviewed 8/2/2022, stated in part, "Hospice personnel will not provide care or service independently until satisfactory completion of required skills competency." Personnel Record 4: Social Worker date of hire 08/09/2021. Review of clinical records revealed the Social Worker began providing care to patients independently in September of 2023. There was no documented evidence in the personnel record of a completed skills competency assessment for the Social Worker prior to the Social Worker providing care. During joint personnel record review on 01/11/2024, the Director of Finance and Human Resources acknowledged that the Social Worker’s competency was incomplete, and they were awaiting the completed form via email from the supervisor.

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient discharged to a Medicare certified facility, the agency did not ensure a copy of the hospice discharge summary was forwarded to the receiving facility. Clinical Record 15: The patient elected the hospice benefit on 01/09/2023, with a terminal diagnosis of severe protein calorie malnutrition. The patient was discharged on 02/04/2023. The discharge note dated 02/04/2023 included documentation that the patient was moving to a veteran facility. The clinical record contained no documented evidence that the hospice discharge summary was sent to the receiving facility. Clinical Record 16: The patient elected the hospice benefit on 06/28/2023, with a terminal diagnosis of malignant neoplasm of pelvic bonds, sacrum, and coccyx. The patient revoked hospice care on 03/16/2023. A discharge note dated 03/16/2023 indicated the patient was admitted to a hospital facility. The clinical record contained no documented evidence that the hospice discharge summary was sent to the hospital facility. During a joint clinical record review and interview on 01/11/2024, the Director of Patient Care Services (DPCS) acknowledged that the electronic medical record provided no evidence of a discharge summary being provided to the facilities. The DPCS stated she remembers coordinating the move for clinical record 15 with the receiving facility, however no evidence of the discharge summary being sent was provided prior to survey exit.

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 interview. In 1 of 2 (50%) clinical records reviewed of patients that reside in a facility, the agency did not ensure the hospice plan of care specified which provider is responsible for performing the functions included in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 08/07/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The updated plan of care dated 08/22/2023 included no documented evidence that the patient resided in a facility and did it identify which provider is responsible for performing the interventions agreed upon and included in the plan of care. During the daily wrap up conference on 01/10/2024, the Director of Patient Care Services, Nurse Practitioner, Director of Finance and Human Resources, and Bereavement Coordinator, and Director of Development acknowledged that the plan of care for this patient in a facility provided no evidence of a delineation of services.

It is required that the designated IDG (interdisciplinary group) member provides the SNF/NF (skilled nursing facility) or ICF/IDF with the following information for each patient/resident, the names and contact information for hospice staff involved in the patient’s care for each patient/resident. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) home visit observations for a patient that resides in a SNF, the agency did not ensure the SNF was provided with the names and contact information for hospice staff involved in the patient’s care. Home Visit 3: During home observation, review of the facility binder, admission information, and medical records revealed no documented evidence that the facility was provided with the names and contact information for hospice staff involved in the patient’s care. During the daily wrap up conference on 01/10/2024, the Director of Patient Care Services, Nurse Practitioner, Director of Finance and Human Resources, and Bereavement Coordinator, and Director of Development acknowledged that the facility did not currently have the names and contact information for hospice staff involved in the patient’s care.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients with hospice aide services, the organization did not ensure the hospice aide provided care consistent with hospice aide training. Clinical Record 2: The Hospice Aide Plan of Care Assignment dated 3/15/23 assigned the hospice aide to provide personal care services to the patient three times per week. The Hospice Aide documented on the aide visit note dated 8/11/23, the patient was "having difficulty breathing and I [the hospice aide] encouraged [the patient's daughter] to give some [as needed] medicine. After [the medication was administered] I [the hospice aide] was able to give [the patient] a bed bath. [The patient] didn't really wake up during the visit. I [hospice aide] called RNCM [Registered Nurse Case Manager] after I left the house." During a joint record review on 8/15/23, the Director of Patient Care Services stated, "The aide can't tell the daughter to give medication. She should have called the RN Case Manager to report the shortness of breath and let the nurse give guidance to the daughter for medications."

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 2 of 3 (67%) clinical records reviewed of patients who received hospice aide services, the organization did not ensure hospice aides reported changes in the patient’s nursing needs to the Registered Nurse (RN) as the changes related to the plan of care. THIS IS A CONTINUING REQUIRED ACTION. Clinical Record 1: The Hospice Aide Plan of Care Assignment dated 8/6/23 assigned the hospice aide to provide personal care services to the patient weekly. The Hospice Aide documented on the aide visit note dated 8/29/23, that the patient's wife refused all personal care services that day, and the RN would be informed of this refusal in a written communication note. The Director of Patient Care Services (DPCS) noted during a joint record review of the clinical record on 8/15/23 that the aide did not document a communication note to the RN until 8/14/23, 5 days after the patient did not receive personal care services as ordered in the aide plan of care assignment. The DPCS stated, "the aide should have contacted the RN the same day the patient's wife refused services." Clinical Record 2: The Hospice Aide Plan of Care Assignment dated 3/15/23 assigned the hospice aide to provide personal care services to the patient three times per week. The Hospice Aide documented on the aide visit note dated 8/11/23, the patient was "having difficulty breathing and I [the hospice aide] encouraged [the patient's daughter] to give some [as needed] medicine. After [the medication was administered] I [the hospice aide] was able to give [the patient] a bed bath. [The patient] didn't really wake up during my visit. I [hospice aide] called RNCM [Registered Nurse Case Manager] after I left the house." The DPCS stated during a joint record review on 8/15/23 that the aide should have contacted the RN right away to inform her of a change in the patient's condition and not after the visit was complete. This is a continued finding from the previous two (2) FOCUS visits, the last focus visit performed on 11/4/22.

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 document review, interview and personnel record review. In 1 of 2 (50%) of personnel records reviewed, the organization did not ensure that the initial orientation addressed employee-specific job duties. Agency policy "Employee Orientations" review date 7/21/22 stated in part, "[Organization] is committed to employing and retaining the best-qualified employees and volunteers and will provide orientation and training opportunities to employees and volunteers that are appropriate to their responsibilities. Training will include policies...to successfully begin assigned job responsibilities." Personnel Record 2: The date of hire for the Director of Patient Care Services (DPCS) was 1/4/23. The DPCS was asked if she had received an orientation to her DPCS role the DPCS stated, "I went around with the previous DPCS for about a week and a half, so yes." Documentation was requested to verify the DPCS’s initial training/orientation. The Interim Executive Director stated, "No one has ever asked for that before. I don't think we document that training, it's one-on-one training." Prior to the exit conference on 8/15/23, the DPCS and Interim Executive Director were unable to provide documented evidence of the DPCS's initial orientation to her job duties.

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 document review, interview and personnel record review. In 1 of 1 (100%) of personnel records reviewed of individuals providing care, the organization did not ensure that the Director of Patient Care Services (DPCS) had a documented assessment of nursing skills and competency according to agency policy. Agency policy "Employee Orientations" review date 7/21/22 stated in part, "[Organization] is committed to employing and retaining the best-qualified employees and volunteers and will provide orientation and training opportunities to employees and volunteers that are appropriate to their responsibilities. Training will include policies...to successfully begin assigned job responsibilities." Personnel Record 2: The date of hire for the Director of Patient Care Services (DPCS) was 1/4/23. When asked if she had a competency assessment of nursing skills and who conducted the nursing skills assessment the DPCS stated, "Yes, I went on visits with the former DPCS for about a week and a half before she left." The DPCS provided a blank copy of a form titled "Competency Assessment Skills Checklist-Registered Nurse" for review. The DPCS stated, "I know I have one of these. I will look for it." The DPCS and Interim Executive Director were unable to locate a completed competency assessment skills checklist for the DPCS before the exit conference on 8/15/23.

It is required that the hospice must take actions aimed at performance improvement and, after implementing those actions, the hospice must measure its success and track performance to ensure that improvements are sustained. This standard was not met as evidenced by document reviews and interviews. THIS IS A CONTINUING PRIOR REQUIRED ACTION. A review of the Governing Body minutes dated between February and October 2022, and QAPI program documents (consisting of quarterly chart audits, and the “Quality Tracking Report" for 2022 which listed scores of indicators, and QAPI meeting minutes for Quarters 2 and 3 of 2022, revealed there was no documentation of goals of achievement and expectations for any of the tracked indicators. Minutes of the QAPI meetings and hospice satisfaction surveys were documented as presented to the Board of Directors and recommendations made by Governing Board members were included in meeting minutes. There was no evidence actions were taken to improve performance in the tracked indicators and no documented assessment of actions taken that could be tied to performance improvement. During interview, the Quality Manager confirmed the finding and stated that she was not aware of any actions taken intended to improve quality indicator performance scores. THIS IS A CONTINUING PRIOR REQUIRED ACTION. A review of the Governing Body minutes between February and October 2022 and QAPI program documents (consisting of quarterly chart audits and a monthly 2022 "Quality Tracking Report" which listed scores of identified indicators) and QAPI meeting minutes for Quarters 2 and 3, 2022 did not describe specific actions taken by the organization to improve performance of tracked QAPI indicators. There was documented goals of achievement and expectations for the tracked indicators to be 100%. Minutes of the QAPI meetings were documented as presented to the Board of Directors and any recommendations made by Governing Board members were included in meeting minutes. Hospice satisfaction survey results were documented as reported to the Governing Body and discussed during the August 2022 board meeting. There was no documentation of any actions taken to improve performance in any of the tracked indicators and there was no documented assessment of any actions taken that could be tied to any improvement improvements or 100% achievement of any performance. During interview, the Quality Manager stated that she was not aware of any actions taken intended to improve quality indicator performance scores. The DPCS stated that she had provided education to some direct care staff members with the goal of improving performance indicators but did not document any one-on-one coaching or education provided.

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 a review of clinical records and interviews. 1 of 3 (33%) clinical records reviewed of patients who received hospice aide services revealed the agency did not ensure aides reported changes in the patient’s nursing needs to a registered nurse as the changes related to the plan of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION Clinical Record 2: was reviewed and identified the patient elected hospice care on 7/26/22. The hospice aide care plan assigned the aide the tasks: bed bath; hair care; skin care; and oral care to be completed at each visit. The aide visit note dated 9/27/22 indicated that hair care was provided to the patient, as the patient’s husband refused to allow the aide to complete other care plan tasks. There was no evidence of communication with the RN Case Manager to report why the assigned aide tasks were not completed. During joint review of the patient record, the DPCS confirmed that she was unable to locate additional documentation of communication between the aide and the RN. THIS IS A CONTINUING PRIOR REQUIRED ACTION. During joint review of the patient record, the DPCS confirmed that she was unable to locate additional documentation of communication between the aide and the RN.

It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by a review of document reviews and interviews. A review of the Governing Body minutes for September 2022 included a proposal for a restructuring of the “vacant” Executive Director position and a new job description. There was no evidence that the Governing Board appointed a qualified Administrator to oversee the agency’s program. During interview, the DPCS confirmed the finding and stated that she was asked to assume the role of the interim Executive Director following the early retirement of the Administrator of record. The DPCS stated that she could provide no documents for review that included her appointment as the interim executive director and stated she had no signed job description or other documents that indicated that she had assumed this role for the agency. The DPCS also stated that she was not aware that a change in Administrator must be reported to the state licensing agency and would “inform the Board of Directors”. A review of the Governing Body minutes for September 2022 included a proposal for a restructuring of the “vacant” Executive Director position and a new job description. No documented evidence in Governing Board minutes included the appointment of a qualified administrator to oversee the agency’s program. During interview, the DPCS stated that she had been asked to assume the role of the interim Executive Director following the early retirement of the Administrator of record. The DPCS stated that she could provide no documents for review that included an appointment of an interim executive director and stated she had no signed job description or other documents that indicated that she had assumed this role for the agency. The DPCS also stated that she was not aware that a change in Administrator must be reported to the state licensing agency within 60 days of that change and would “inform the Board of Directors” of this requirement.

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 review of clinical records and interview. In 3 of 7 (43%) applicable clinical records of patients receiving spiritual counselor services, there was no documented evidence that Spiritual Counselor visits were completed, as assigned on the Hospice plan of care. Record #53040 - The Spiritual Counselor visit frequency was "one PRN". There was an extra Spiritual Counselor visit on 10/19/21. Record #82845 - The Spiritual Counselor visit frequency was "one PRN". There were extra Spiritual Counselor visits on 8/24/21, 8/31/21 and 9/9/21. Record #84600 - The Spiritual Counselor visit frequency was "one PRN". There was an extra Spiritual Counselor visit on 12/29/21. During interview, the Clinical Services Director confirmed that there were no additional physician's orders for these extra visits by the spiritual counselor.

It is required that the hospice takes action to improve performance, assesses the success of the action after implementing it, and tracks ongoing results to ensure improvement is sustained. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by document review and interview. A review of the Governing Body minutes and/or QAPI program documents did not describe specific actions taken by the organization to improve performance of tracked QAPI indicators. There was no specific documentation of goals of achievement and expectations for any of the tracked indicators. There was no documentation of actions taken to improve performance or an assessment of the actions after implementing actions to improvement performance. The QAPI program documents consisted of quarterly chart audits and a monthly 2021 "Quality Tracking Report" which listed scores of identified indicators. During interview, the Quality Manager stated that the QAPI meetings were scheduled quarterly and cancelled since April 2021. The Quality Manager stated that hospice satisfaction surveys had not been completed during 2021 since the hospice moved to a new electronic medical record system. The agency policy, "Quality Assessment and Performance Improvement", no policy number, includes, in part, "An overview of the status of the Performance Improvement Priorities will be presented by the Director of Quality to the QAPI and Corporate Compliance Committee of the Board of Directors during a meeting held quarterly, and "Targets for performance in the areas that are being monitored will be set by the QAPI team". There was no evidence that the hospice took action to improve performance.

It is required that the hospice maintains a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The infection control program includes a method for identifying infectious and communicable disease problems and a plan for implementing appropriate actions that are expected to result in improvement and disease prevention. This standard was not met as evidenced by document review and interview. There was no evidence that the hospice maintained a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases or that the infection control program included a method for identifying infectious and communicable disease problems and a plan for implementing appropriate actions that are expected to result in improvement and disease prevention. The identification of Infections of both patients and staff, to include COVID-19 infections, were not included or part of the QAPI or infection control program. There were no documented infection reports, the "Quality Tracking Indicators" did not include tracking of infections, and/or there were no QAPI committee meetings since April 2021 which addressed the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. During interview, the Quality Manager confirmed that she was not tracking infections and stated, "I think there is a infection report for patients that can be pulled from the clinical record".

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by document review , personnel record review, and interview. In 2 of 5 (40%) applicable personnel records of direct employees, contracted physicians and patient care volunteer, there was no documented evidence that annual infection control education was completed, as required in agency policy. Policy "Infection Control Plan", no Policy number, approval date 8/22/16 and last review date 9/1/20, included, in part, "Infection control in-services will be scheduled no less than annually", "Attendance will be mandatory and will be documented" and "Records of in-service attendance will be maintained in the personnel file". The HR Coordinator was interviewed and confirmed that she could not locate the missing infection control in-services for 2021. (Record #"s: Associate Medical Director #63445 and Social Worker #98143).

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 review of clinical records with the Clinical Services Director and interview. In 2 of 5 (40%) applicable clinical records of patients who received Hospice Aide services, there was no documented evidence that the Hospice Aide was compliant with visits as assigned in the Hospice plan of care. Record #53040 - The Hospice Aide visit frequency was ordered on 9/26/21 for two times a week. There were two hospice aide visit notes missing the weeks of 9/26/21, 10/3/21 and 10/10/21. Record #91183 - The Hospice Aide visit frequency was ordered on 8/11/21 for two times a week. There were two hospice aide visit notes missing the weeks of 9/5/21, 9/12/21 and 9/19/21. During interview, the Clinical Services Director confirmed she could not locate the missing Hospice Aide visit notes, or missed visit reports regarding these missed hospice aide visits.

It is required that hospice aides 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. This standard was not met as evidenced by clinical record review and interview. 2 of 5 (40%) applicable records of patients who received hospice aide services revealed, the hospice did not ensure aides reported changes in the patient’s nursing, and/or social needs to a registered nurse as the changes related to the plan of care. . Record #37661 - The Hospice Aide plan of care assigned the Hospice Aide to perform "personal care, skin care and shampoo" each visit. The Hospice Aide visit note dated 1/7/22 included that the personal care, skin care and shampoo were not completed and "patient refused". There was no documented communication that this change was reported to the RN by the hospice aide. Record #53040 - The Hospice Aide plan of care assigned the Hospice Aide to perform "personal care, hair care, skin care, check pressure areas and oral care" each visit. The Hospice Aide visit note dated 9/20/21 did not included if the "personal care, hair care, skin care, check pressure areas and oral care" were completed. There was no documented communication with the Hospice RN as to why the assigned Hospice Aide tasks were not completed. During interview, the Clinical Service Director confirmed that she was unable to locate additional documentation of communication between the hospice aide and the the RN.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by document review and interviews. Review of the governing body meeting minutes dated 5/20/21, 6/17/21, 8/19/21, 9/23/21 and 10/21/21 only included, related to performance improvement and patient safety program, "Quality tracking indicators: included for your review" with no documented evaluation by the governing body of the Quality Tracking Indicators. There was no evidence that the governing body included the development of the Performance Improvement Plan for the coming calendar year, as required in policy. There was no evidence that an overview of the status of the performance improvement priorities was presented to the QAPI committee, as required by agency policy. There were no quarterly QAPI committee meetings since April 2021. During interview, the Quality Manager stated that even though the quarterly QAPI committee meetings were not conducted, that the "Quality Tracking Report 2021" was given to the Executive Director, who then reviewed the report at each Governing Body meeting. The agency policy, "Quality Assessment and Performance Improvement QAPI Policy and Procedures", no policy number, included, in part, "The Quality Assessment, Performance Improvement Program will comply with all the requirements of the Medicare Conditions of Participation and the State Hospice Standards", "An overview of the status of the performance improvement priorities will be presented by the Director of Quality to the QAPI and Corporate Compliance Committee of the Board of Directors during a meeting held quarterly", and "The last meeting of the calendar year will also include the development of the Performance Improvement Plan for the coming calendar year".

It is required that the hospice ensures that the durable medical equipment (DME) is safe and in working order as intended for use in the patient’s environment. The hospice ensures that the manufacturer’s guidelines for performing routine maintenance and preventive maintenance are followed. The hospice ensures that repair and maintenance policies are developed when manufacturer’s guidelines for a piece of equipment do not exist. The hospice may use persons under contract to ensure maintenance and repair of durable medical equipment. This standard was not met as evidenced by observation and interview. The hospice did not ensured that the durable medical equipment (DME) was safe and in working order as intended for use in the patient’s environment, that the manufacturer’s guidelines for performing routine maintenance and preventive maintenance were followed and that repair and maintenance policies were developed when manufacturer’s guidelines for a piece of equipment do not exist. Observation of the office environment revealed wheelchairs, shower chairs, walkers and bedside commodes being stored around the conference room. During interview, the Clinical Service Director stated that one of their DME providers was no longer in business and gave the wheelchairs, shower chairs, walkers and bedside commodes to the hospice, and the hospice delivers these DME items to the hospice patient. When the patient no longer needs the DME, it is returned to the hospice office for cleaning by the nursing staff and/or maintenance technician, and stored in a clean and/or dirty storage room. The Director confirmed the hospice does not have policies and procedures on this DME process, or evidence of the manufacturer’s guidelines for performing routine maintenance and preventive maintenance, and does not currently have repair and maintenance policies for DME.