Every finding on record at Hummingbird Hospice, LLC

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician, a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review in which a patient revoked hospice care, the hospice did not ensure a copy of the discharge summary was forwarded to the patient’s attending physician. Clinical Record 14: The patient elected the hospice benefit on 12/2/2022. The patient revoked hospice care on 07/08/2023. The clinical record contained no documented evidence a discharge summary was forwarded to the patient's attending physician. During review of findings and interview on 11/30/2023, the Alternate Administrator/Registered Nurse confirmed the findings that the record did not include documentation of a discharge summary. In 1 of 1 (100%) clinical record in which a patient revoked the election of hospice care revealed the hospice did not ensure that a copy of the discharge summary was forwarded to the patient’s attending physician.

Based on document review and interview, the Department determined the facility failed to annually measure factors such as patient safety, clinical outcomes, patient satisfaction, and adherence to clinical guidelines. The deficient practice posed a risk as a quality assessment and performance improvement (QAPI) program documents the necessary information required to effectively measure and evaluate healthcare services and implement changes to improve patient outcomes, reduce medical errors, and improve patient satisfaction. --- Findings include: A review of the facilitys policies and procedures revealed a policy titled ";Improving Organizational Performance; Policy No. 3-001" (revised May 2022). The policy stated ";... The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, and maintained, and is evaluated annually". A review of the facilitys policies and procedures revealed a policy titled ";Patient Focused Performance Improvement; Policy No. 3-002" (revised May 2022). The procedure stated ";... 1. As part of the organization-wide performance improvement process, opportunities for improvement related to patient outcomes will be identified through continuous measurement of patient satisfaction survey results, clinical/service record review, monitoring of incidents and infection control reports and Adverse Event Outcomes Reports... 4. Performance Improvement documentation will be maintained by the Performance Improvement Coordinator". The hospice's QAPI program report dated within the last 12 months and submitted to the hospice's governing authority was requested, none was provided The hospice's governing body minutes outlining the annual evaluation of the quality assessment and performance improvement program was requested, none was provided In a joint interview conducted on March 30, 2023 with Employees #1 and #2, Employee #1 confirmed the last QAPI meeting was held on February 10, 2021 and confirmed the facility was unable to provide governing body minutes outlining the annual evaluation of the QAPI program.

Based on document review and interview, it was determined the facility failed to implement and maintain an ongoing, hospice-wide data-driven quality assessment and performance improvement efforts. The facility failed to ensure the governing body's responsibility to maintain an organization-wide performance improvement program. The facility's governing body failed to provide adequate oversight in the quality improvement of patient safety, clinical outcomes, patient satisfaction, and adherence to clinical guidelines. The deficient practice posed a risk as inadequate governing authority may not be able to ensure that the organization is in compliance with relevant laws, regulations, and policies. --- Findings include: A review of the facilitys policies and procedures revealed a policy titled ";Improving Organizational Performance; Policy No. 3-001" (revised 2022). The policy stated ";... The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, and maintained, and is evaluated annually". A review of the facilitys policies and procedures revealed a policy titled ";Governing Body; Policy No. 8-003" (revised 2022). The procedure stated ";..Executive Director/Administrator will be monitored regularly through a procedureestablished by the Governing Body. The process and documentation will reflect that: A. Relevant findings of performance improvement activities are consistently provided to the Governing Body to allow for oversight of the quality assessment and performance improvement (QAPI) program. The governing body will ensure the following: 1. That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; 2. That the program reflects the complexity of its organization and services and that it addresses all services including services provided under contract or arrangement; 3. That the organization-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; 4. That focuses on indicators related to improved outcomes; 5. That clear expectations for patient safety are established, implemented, and maintained. ". The hospice's QAPI program report dated within the last 12 months and submitted to the hospice's governing authority was requested, none was provided. The hospice's governing body minutes outlining the annual evaluation of the quality assessment and performance improvement program was requested, none was provided. In a joint interview conducted on March 30, 2023 with Employees #1 and #2, Employee #1 confirmed the last QAPI meeting was held on February 10, 2021 and confirmed the facility was unable to provide governing body minutes outlining the annual evaluation of the QAPI program.

Based on documentation review, record review, and interview, it was determined the hospice failed to implement policies and procedures created to ensure the protection of the clinical record from unauthorized use. The deficient practice posed a risk to patient care by compromising the accuracy and integrity of clinical record. --- Findings include: A review of facility policies and procedures revealed a policy titled "Clinical Record Review; PolicyNo.3-007" (revised May 2022). The procedure stated "... Each clinical record will be reviewed on an ongoing basis .. for:...D. Completeness of the clinical records, E. The accuracy of clinical records..." A review of Patient #9's clinical record revealed the clinical record was incomplete. A review of Patient #10s clinical record revealed the clinical record was incomplete. In a joint interview conducted on March 30, 2023 with Employee #1 and #2, Employee #1 reported patient #10s clinical record was incomplete because a facility employee had the missing documents in their vehicle. Employee #1 reported employees are supposed to bring the clinical record back before closing and secure the clinical records in a locked cabinet to prevent unauthorized access. Employee #1 and #2 acknowledged the facility failed to ensure the security of the clinical record. A review of Patient #8s physical clinical record revealed a document titled ";Hospice Nursing Clinical Note" dated on March 10, 2023, signed by Employee #4 at 13:30. A review of Patient #8s electronic clinical record revealed a document titled ";Hospice Nursing Clinical Note" dated on March 10, 2023, signed by Employee #4 at 13:30. Both clinical notes in the physical clinical record and electronic record contained 3 subsections that were titled ";Skilled Observation, Skilled intervention/treatment/Teaching/Pt/Cg Response, and Coordination Plan". However, the clinical notes were not identical. The sections titled ";Skilled Observation" contained 19 discrepancies between the two documents for the identified sections. Furthermore, the section titled ";Skilled intervention/treatment/Teaching/Pt/Cg Response" contained 4 discrepancies between the two documents for the identified sections. Lastly, the sections titled ";Coordination Plan" contained 2 inaccuracies between the two documents for the identified sections. In an interview conducted on March 30, 2023 with Employee #1, Employee #1 was requested to provide clarity on the discrepancies between the two hospice nursing clinical notes that were signed and dated on the same date. Employee #1 was unable to provide an explanation that could account for differences in 3 aforementioned sections.

It is required that each patient’s individualized written plan of care reflects patient and family goals This standard was not met as evidenced by a review of clinical records and interviews. 8 of 8 (100%) clinical records reviewed revealed the hospice did not ensure the patient's individualized plan of care reflected patient and family goals based on the problems identified in the initial, comprehensive, and/or updated comprehensive assessments. THIS IS A CONTINUING PRIOR REQUIRED ACTION Clinical Record 4 Dates of service reviewed 8/12/22 through 9/12/22. The initial and updated comprehensive spiritual assessments identified the need for spiritual support and the initial and updated comprehensive psychosocial assessments identified the need for social services support. Review of the clinical record revealed missing plan of care goals for the identified psychosocial and spiritual care plan problems and interventions. Clinical Record 5 Dates of service reviewed 7/12/22 through 8/12/22. The initial and updated comprehensive spiritual assessments identified the need for spiritual support and the initial and updated comprehensive psychosocial assessments identified the need for social services support. Review of the clinical record revealed missing plan of care goals for the identified psychosocial and spiritual care plan problems and interventions. Clinical Record 8 Dates of service reviewed 7/7/22 through 8/7/22. The initial and updated comprehensive spiritual assessments identified the need for spiritual support and the initial and updated comprehensive psychosocial assessments identified the need for social services support. Review of the clinical record revealed missing plan of care goals for the identified psychosocial and spiritual care plan problems and interventions. Clinical Record 1 Dates of service reviewed 6/18/22 through 7/18/22. The initial and updated comprehensive spiritual assessments identified the need for spiritual support and the initial and updated comprehensive psychosocial assessments identified the need for social services support. Review of the clinical record revealed missing plan of care goals for the identified psychosocial and spiritual care plan problems and interventions. Clinical Record 7 Dates of service reviewed 3/9/22 through 4/9/22. The updated comprehensive spiritual assessments identified the need for spiritual support and the updated comprehensive psychosocial assessments identified the need for social services support. Review of the clinical record revealed missing plan of care goals for the identified psychosocial and spiritual care plan problems and interventions. Clinical Record 2 Dates of service reviewed 8/12/22 through 9/12/22. The initial and updated comprehensive spiritual assessments identified the need for spiritual support and the initial and updated comprehensive psychosocial assessments identified the need for social services support. Review of the clinical record revealed missing plan of care goals for the identified psychosocial and spiritual care plan problems and interventions. Clinical Record 6 Dates of service reviewed 9/2/22 through 9/29/22. The initial and updated comprehensive spiritual assessments identified the need for spiritual support and the initial and updated comprehensive psychosocial assessments identified the need for social services support. Review of the clinical record revealed missing plan of care goals for the identified psychosocial and spiritual care plan problems and interventions. Clinical Record 3 Dates of service reviewed 8/24/22 through 9/24/22. The initial and updated comprehensive spiritual assessments identified the need for spiritual support and the initial and updated comprehensive psychosocial assessments identified the need for social services support. Review of the clinical record revealed missing plan of care goals for the identified psychosocial and spiritual care plan problems and interventions. During joint clinical record review and interview 9/29/22, the RN CEO. Alternate Administrator and Alternate Clinical Director confirmed the missing plan of care goals. THIS IS A CONTINUING PRIOR REQUIRED ACTION During joint clinical record review and interview 9/29/22, the RN CEO. Alternate Administrator and Alternate Clinical Director confirmed the missing plan of care goals.