Every finding on record at Integrity Hospice Care LLC

It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including: 1. Participation in a full-scale exercise that is community-based every two (2) years. a) When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. b) If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. 2. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to a) A second full-scale exercise that is community-based or a facility-based functional exercise; or b) A mock disaster drill; or c) A tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. Agency policy 2.5.1 Testing Program for Emergency Operations Plan (EOP) (Dated: 6/2017) stated in part, "Hospice will conduct exercise to test the EOP at least annually. Hospice will do the following: Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based exercise. Hospice is encouraged to seek out local emergency agencies and health care coalitions to participate in a full-scale, community-based exercise. If Hospice experiences an actual natural or man-made emergency that requires activation of the EOP, Hospice is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one (1) year following the onset of the actual event." Review of the Emergency Preparedness binder and emergency preparedness documentation revealed no documented evidence that the agency activated, tested or participated in a full-scale exercise annually for 2020, 2021, and 2022. The agency did not ensure full-scale exercises were conducted to test the emergency operation plan at least annually or as warranted. During an interview on 10/20/2023, the Chief Executive Officer /Director of Clinical Services stated "We are activating our emergency plan and doing things but not taking credit and not documenting. The last one we had was a flood in the spring; all the communications was via tiger text." The Chief Executive Officer /Director of Clinical Services and the Administrator agreed the agency did not ensure activation and/or full-scale exercise testing of the EOP for 2020, 2021, or 2022. The hospice did not ensure the emergency operations plan was activated and/or tested and documented annually for 2020, 2021, and 2022. The agency also did not ensure full-scale exercises were conducted to test the emergency operation plan at least annually or as warranted.

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 IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records, policies, and interviews with the Chief Executive Officer/Director of Clinical Services and the Administrator which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure of the Registered Nurse to ensure coordination of care and continuous assessment of the patient's and family's needs (HCPC.19.I/L540); Failure to ensure goal(s) and intervention(s) for volunteer services provided were include in the patients’ plan of care (HCPC.21.I/L545); Failure to ensure the patient’s individualized written plan of care included the drugs and treatments necessary to meet the needs of the patient (HCPC.21.I/L549); Failure to ensure the individualized plan of care included the scope and frequency of services necessary to meet the patient's needs (HCPC.21.I/L547); and Failure to ensure documented review and revision of patients’ individualized care plans as frequently as the patient's condition requires, but no less frequently than every 15 days (HCPC.22.I/L552). The cumulative effect of these deficiencies has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.56, Interdisciplinary Group, Care Planning, and Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving home health care services from the agency.

It is required that the hospice designates a Registered Nurse 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 (POC). This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the Registered Nurse (RN) provided coordination of care and ensured continuous assessment of the patient's and family needs and ensured implementation of the interdisciplinary plan of care. Agency policy 9.22 Nursing Services (Revised 2014) stated in part, "Nursing care will be provided in accordance with the patient's IDG plan of care, under the supervision of a Registered Nurse." Clinical Record 5: The patient elected the hospice benefit on 06/06/2023. Clinical record review revealed the Licensed Vocational Nurse (LVN) provided nursing visits on 09/06/2023, 09/13/2023, 09/20/2023, 09/27/2023, 10/04/2023, 10/11/2023, and 10/17/2023 with no evidence of coordination of care with the RN. The RN provided nursing visits on 08/25/2023 and 10/19/2023. The clinical record contained no evidence of coordination or communication notes between the RN and LVN. There was no documented evidence in the clinical record of RN coordination of care or continuous assessment of the patient’s and family’s needs between 08/25/2023 and 10/19/2023. During an interview on 10/20/2023, the Chief Executive Officer /Director of Clinical Services and the Administrator agreed the agency did not ensure the RN provided coordination of care, continued assessment of each patient's and family needs, and oversight of the implementation of the interdisciplinary POC.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed with volunteer services, the agency did not ensure the plan of care included volunteer goal(s) and intervention(s). Agency policy 9.12 IDG Care Planning Process (Dated: 2014) stated in part, "The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments." Clinical Record 8: The patient elected the hospice benefit on 06/20/2023. Clinical record review revealed the patient was receiving volunteer services. The plan of care dated 10/18/2023 contained no documented evidence of goal(s) and intervention(s) for the volunteer services provided. During an interview on 10/20/23, the Chief Executive Officer /Director of Clinical Services and the Administrator reviewed the record and agreed the agency did not ensure the plan of care included goal(s) and intervention(s) for the volunteer services being provided.

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Agency policy 9.12 IDG [interdisciplinary group] Care Planning Process (Revised 2014) stated in part, "The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including: a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs." Clinical Record 8: The patient elected the hospice benefit on 06/20/2023. The plan of care dated 10/18/2023 did not include documentation of the scope and frequency of services for Skilled Nurse, Social Worker, Chaplain, and Hospice Aide. The clinical record included documented visit notes for the Registered Nurse, Social Worker, Chaplain, and Hospice Aide. Clinical Record 10: The patient elected the hospice benefit on 08/09/2023. The plan of care dated 10/08/2023 did not include documentation of the scope and frequency of services for Skilled Nurse, Social Worker, Chaplain, and Hospice Aide. The clinical record included documented visit notes for the Registered Nurse, Licensed Vocational Nurse, Social Worker, Chaplain, and Hospice Aide. During joint clinical record review on 10/19/2023, the Chief Executive Officer /Director of Clinical Services stated there have been challenges in completing the plan of care and that more education is needed in using the electronic medical record system and agreed the agency did not ensure the plan of care included a detailed statement of the scope and frequency of services.

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 drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the individualized plan of care included the drugs and treatment necessary to meet the needs of the patient. Agency policy 9.12 IDG Care Planning Process (Revised 2014) stated in part, "The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including: drugs and treatments necessary to meet the needs of the patient." Clinical Record 10: The patient elected the hospice benefit on 08/09/2023. Review of the medication profile revealed the patient was using oxygen. The plan of care dated 10/18/2023 did not include oxygen. During joint record review on 10/19/2023, the Chief Executive Officer /Director of Clinical Services stated there have been challenges in completing the plan of care and more education is needed in using the electronic medical record system.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the individualized care plan was reviewed or revised as the patient's condition requires, but no less frequently than every 15 calendar days. Agency policy 9.12 IDG [interdisciplinary group] Care Planning Process (Revised 2014) stated in part "The IDG (in collaboration with the patient's attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient's condition requires, but no less than every 15 calendar days." Clinical Record 1: The patient elected the hospice benefit on 08/18/2023. Clinical record review revealed the initial plan of care was dated 08/18/2023 and reviewed/revised on 08/21/2023. The clinical record contained no documented evidence the plan of care was reviewed or revised after 08/21/2023, as of the date of record review on 10/19/2023. Clinical Record 2: The patient elected the hospice benefit on 09/28/2023. Clinical record review revealed the initial plan of care was dated 09/28/2023 and reviewed/revised on 10/01/2023. The clinical record contained no documented evidence the plan of care was reviewed or revised after 10/01/2023, as of the date of record review on 10/19/2023. Clinical Record 5: The patient elected the hospice benefit on 06/06/2023. Clinical record review revealed the initial plan of care was dated 06/06/2023 and reviewed/revised on 10/01/2023. The clinical record contained no documented evidence the plan of care was reviewed or revised after 10/01/2023, as of the date of record review on 10/19/2023. During an interview on 10/20/2023 Chief Executive Officer /Director of Clinical Services and the Administrator agreed the agency did not ensure the patients’ plans of care were updated / reviewed at least every 15 days.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program Is evaluated annually. This standard was not met as evidenced by document review and interview. Agency policy 10.1 Quality Assessment and Performance Improvement (QAPI) Plan (Dated: 2015) stated in part, "The QAPI program will be evaluated annually by the Governing Body as part of the annual program evaluation." Review of the agency’s QAPI binder and QAPI information revealed no documented evidence that an annual QAPI program evaluation was completed for 2020, 2021, and 2022. During an interview on 10/20/23, the Chief Executive Officer /Director of Clinical Services stated, "I have not completed, on paper, an annual program evaluation for 2020, 2021, and 2022." The agency did not ensure that there was as an annual QAPI Program evaluation completed for 2020, 2021, and 2022.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure clinicians performed hand hygiene as required by agency policy. Agency policy Hand Hygiene Policy and Compliance Program (Revised 2016) stated in part, "Indications for handwashing and hand antisepsis...after direct patient care...after removing gloves." Home Visit 3: During home visit observation with the Registered Nurse (RN), the nurse was observed reaching into her pocket with gloved hands twice to silence the cell phone and then continued with patient care without removing gloves and completing hand hygiene. The nurse was also observed to remove gloves after patient care but did not perform hand hygiene when gloves were removed. During review of findings on 10/19/2023, the Chief Executive Officer /Director of Clinical Services and the Administrator agreed the clinician did not follow the hand hygiene guidelines as required per agency policy.

It is required that licensed professional services provided directly or under arrangement are supervised only by appropriately qualified health care professionals who meet the appropriate qualifications and who practice under the hospice’s policies and procedures. This standard was not met as evidenced by personnel record review and interview. In 1 of 7 (14%) personnel records reviewed for licensed professional staff, the agency did not ensure that licensed professional services were supervised by appropriately qualified healthcare professionals. Personnel Record 10: Master of Social Work (MSW) date of hire 10/05/2020. The personnel record contained no documented evidence that the MSW was supervised and evaluated by an MSW. The personnel record included an initial evaluation dated 10/5/2020 that was signed by the BSW (Bachelor of Social Worker). During review of findings on 10/18/2023, the Chief Executive Officer /Director of Clinical Services agreed that the MSW should be supervised by another MSW, the BSW is not qualified to evaluate the MSW.

It is required that the hospice provides nursing care under the supervision of a Registered Nurse (RN). This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 4 (25%) clinical records reviewed for patients that received Licensed Vocational Nursing (LVN) services, the agency did not ensure nursing care provided by the LVN was supervised by the RN at least every 30 days as required by agency policy. Agency policy 9.22 Nursing Services (Revised: 2014) stated in part, "The hospice provides nursing care under the supervision of a Registered Nurse…the LVN supervisory visits are completed at least every 30 days." Clinical Record 5: The patient elected the hospice benefit on 06/06/2023. Review of the clinical record revealed the LVN provided nursing visits dated 09/06/2023, 09/13/2023, 09/20/2023, 09/27/2023, 10/04/2023, 10/11/2023, and 10/17/2023. The clinical record contained no documented evidence of LVN supervisory visits completed by the RN at least every 30 days. During an interview on 10/20/2023, the Chief Executive Officer /Director of Clinical Services and the Administrator agreed the agency did not ensure LVN supervisory visits were documented by the RN at least every 30 days.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 2 (100%) bereavement records reviewed, the agency did not ensure that bereavement services reflected the needs of the bereaved per a bereavement plan of care. Agency policy 4.26 Bereavement Services (Revised 2014) stated in part, "Unless Bereavement Servies have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated, which may include telephone support, letters and cards, etc." Clinical Record 13: The patient elected the hospice benefit on 04/04/2023, with a terminal diagnosis of nontraumatic subdural hemorrhage. The patient’s death was dated 04/04/2023. Clinical record review revealed no documented evidence of bereavement services being offered, whether the services were refused or accepted and a post-death bereavement plan of care. Clinical Record 14: The patient elected the hospice benefit on 10/25/2022, with a terminal diagnosis of heart disease. The patient’s death was dated 10/25/2022. Clinical record review revealed no documented evidence of bereavement services being offered, whether the services were refused or accepted and a post-death bereavement plan of care. During an interview with the Bereavement Coordinator (BC) on 10/20/2023, the BC confirmed the records provided no evidence of refusal of services or initiation of a post death bereavement plan of care. The BC stated a phone call was made to the daughter of Clinical Record 13 and the daughter refused post-death bereavement services, but it was not documented in the clinical record. During record review and interview on 10/20/2023, the Chief Executive Officer /Director of Clinical Services and the Administrator agreed that the agency did not ensure post-death bereavement plans of care for the bereaved.

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 Registered Nurse (RN) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 10 (20%) clinical records reviewed with hospice aide services, the agency did not ensure the hospice aide care plan assignment developed by the RN provided specific written patient care instructions for the aide. Agency policy Nursing Services (Revised: 2014) stated in part, "Professional nursing service will be provided by a registered nurse and include... assigning Hospice Aide to a specific patient." Clinical Record 2: The patient elected the hospice benefit on 09/28/2023, with a terminal diagnosis of Alzheimer's disease. On the hospice aide plan of care assignment dated 09/28/2023, the RN assigned the task for bathing. The task included the following: a complete bed bath; a partial bed bath (patient assist); and a shower. The aide plan of care instructions allowed the aide to determine the type of bath to provide and did not include specific instructions or parameters for the aide to follow when determining the type of bath to provide. Clinical Record 3: The patient elected the hospice benefit on 01/03/2023, with a terminal diagnosis of Alzheimer's disease. On the hospice aide plan of care assignment dated 01/03/2023, the RN assigned the task for bathing. The task included the following: a complete bed bath; a partial bed bath (patient assist); and a shower. The aide plan of care instructions allowed the aide to determine the type of bath to provide and did not include specific instructions or parameters for the aide to follow when determining the type of bath to provide. During an interview on 10/20/23, the Chief Executive Officer /Director of Clinical Services and the Administrator reviewed the findings and agreed the agency did not ensure that the hospice aide care plan, developed by the RN, provided specific written patient care instructions for the aide.

It is required that hospice aides are supervised by a Registered Nurse (RN) 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 document review, clinical record review, and interview. In 4 of 9 (44%) clinical records reviewed for patients that elected hospice aide services, the Registered Nurse did not ensure hospice aides were supervised no less frequently than every 14 days. Agency policy 9.22 Nursing Services (Revised: 2014) stated in part, "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." Clinical Record 1: The patient elected the hospice benefit on 08/18/2023. The plan of care dated 08/18/2023 included an order for hospice aide frequency of visits twice per week. The clinical record contained an aide supervisory visit dated 08/30/2023, the next supervisory visit was dated 09/14/2023, 15 days after the supervisory visit dated 08/30/2023. Clinical Record 3: The patient elected the hospice benefit on 01/03/2023. The plan of care dated 08/31/2023 included an order for hospice aide frequency of visits twice per week. The clinical record contained no documented evidence of aide supervisory visits completed by the RN from 08/31/2023 to 10/19/2023. Clinical Record 5: The patient elected the hospice benefit on 06/06/2023. The plan of care dated 08/25/2023 included an order for hospice aide frequency of visits twice per week. The clinical record contained no documented evidence of aide supervisory visits completed by the RN from 08/25/2023 to 10/19/2023. Clinical Record 10: The patient elected the hospice benefit on 08/09/2023. The plan of care dated 08/09/2023 included an order for hospice aide frequency of visits twice per week. The clinical record contained an aide supervisory visit dated 09/28/2023, the next supervisory visit was dated 10/17/2023, 19 days after the supervisory visit dated 10/17/2023. During record review and interview on 10/19/2023, the Chief Executive Officer /Director of Clinical Services acknowledged that the RNs were not completing timely aide supervisory visits and stated the RNs should complete this task at each visit to ensure appropriate supervision.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. Review of the agency's volunteer program revealed the agency did not ensure the Volunteer Program documented and demonstrated viable, and ongoing efforts to recruit and retain volunteers for 2021, 2022, and 2023. Agency policy 4.24 Volunteer Services (Dated: 3/2013) stated in part, "Hospice will document active and ongoing efforts to recruit and retain volunteers." During an interview on 10/20/2023, the Volunteer Coordinator stated "I have not been documenting the recruitment and retention efforts completed. I am fairly new in this role and will start tracking and keeping evidence immediately." During an interview on 10/20/2023, the Chief Executive Officer/Director of Clinical Services and the Administrator agreed the agency did not ensure documentation of the volunteer program recruitment and retention efforts. The agency did not ensure that the Volunteer Program had documented and demonstrated viable and ongoing efforts to recruit and retain volunteers for 2021, 2022, and 2023.

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, personnel record review, and interview. In 7 of 9 (78%) personnel records reviewed for staff that provide care and services to patients, the agency did not ensure staff skills and competencies were assessed per agency policy. Agency policy 4.28 Staff Competency Program (revised 2014) stated in part, "Competency evaluations are performed at time of hire and annually." Personnel Record 2: Chief Executive Officer /Director of Clinical Services /Registered Nurse (RN) date of hire 04/21/2021. The personnel record contained no documented evidence of RN competency evaluations for 2021 and 2022. Personnel Record 4: Registered Nurse /Alternate Director of Clinical Services date of hire 09/02/2019. The personnel record contained no documented evidence of RN competency evaluations for 2021 and 2022. Personnel Record 5: Hospice Aide date of hire 08/13/2018. The personnel record contained no documented evidence of an aide competency being completed within the previous 12 months. The record had evidence of aide competency evaluations dated 8/13/2021 and 09/16/2022. Personnel Record 7: Chaplain/Bereavement Coordinator (BC) date of hire 07/08/2019. The personnel record contained no documented evidence of a Chaplain competency evaluation for 2021 or a BC competency evaluation for 2021 and 2022. Personnel Record 8: Nurse Practitioner (NP) date of hire 10/19/2020. The personnel record contained no documented evidence of a completed NP competency evaluation for 2021 and 2022. Personnel Record 9: Bachelor of Social Work (BSW) date of hire 04/19/2016. The personnel record contained no documented evidence of a completed BSW competency evaluation for 2021 and 2022. Personnel Record 10: Master of Social Work (MSW) date of hire 10/05/2020. The personnel record contained no documented evidence of a completed MSW competency evaluation for 2021 and 2022. During review of findings and interview on 10/18/2023, the Chief Executive Officer /Director of Clinical Services and the Administrator reviewed the personnel records and agreed competency evaluations had not been completed as required by agency policy.

It is required that each patient’s record includes, at a minimum the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by document review, clinical record review, and interview. In 8 of 10 (80%) clinical records reviewed with hospice aide services, the agency did not ensure the hospice aide completed visit notes in the electronic medical record per agency policy. Agency policy 11.3 Hospice Aide Documentation (Revised 2014) stated in part, "The original documentation will be filled in the medical record within seven (7) days of the visit." Clinical Record 1: The patient elected the hospice benefit on 08/18/2023. The plan of care dated 08/18/2023, ordered the hospice aide frequency of visits twice a week. The clinical record contained no documented evidence of hospice aide visits for the weeks of 10/08/2023 and 10/15/2023 and no documentation of missed visits, as of the date of record review on 10/19/2023. Clinical Record 2: The patient elected the hospice benefit on 09/28/2023. The plan of care dated 09/28/2023, ordered the hospice aide frequency of visits twice a week. The clinical record contained one documented hospice aide visit dated 09/29/2023. There was no documented evidence of hospice aide visits after 09/29/2023 and no documentation of missed visits by the aide, as of the date of record review on 10/19/2023. Clinical Record 4: The patient elected the hospice benefit on 09/26/2023. The plan of care dated 09/26/2023, ordered the hospice aide frequency of visits twice a week. The clinical record revealed no documented evidence of hospice aide visits being provided to the patient or documentation of missed visits by the aide, as of the date of record review on 10/19/2023. Clinical Record 6: The patient elected the hospice benefit on 05/03/2023. The plan of care dated 05/03/2023, ordered the hospice aide frequency of visits twice a week. The clinical record revealed no documented evidence of hospice aide visits being provided to the patient or documentation of missed visits by the aide, as of the date of record review on 10/19/2023. Clinical Record 7: The patient elected the hospice benefit on 03/15/2023. The plan of care dated 03/15/2023, ordered the hospice aide frequency of visits twice a week. The clinical record contained no documented evidence of hospice aide visits for the weeks of 10/01/2023, 10/08/2023 and 10/15/2023 and no documentation of missed visits, as of the date of record review on 10/19/2023. Clinical Record 8: The patient elected the hospice benefit on 06/20/2023. The plan of care dated 06/20/2023, ordered the hospice aide frequency of visits twice a week. The clinical record contained no documented evidence of hospice aide visits for the weeks of 10/01/2023, 10/08/2023 and 10/15/2023 and no documentation of missed visits, as of the date of record review on 10/19/2023. Clinical Record 9: The patient elected the hospice benefit on 05/17/2023. The plan of care dated 09/09/2023, ordered the hospice aide frequency of visits twice a week. The clinical record contained one documented hospice aide visit dated 06/12/2023. There was no documented evidence of hospice aide visits after 06/12/2023 and no documentation of missed visits by the aide, as of the date of record review on 10/19/2023. During an interview with the hospice aide on 10/19/2023, the aide confirmed she was still seeing the patient but was behind on documenting visit notes in the electronic medical record. Clinical Record 10: The patient elected the hospice benefit on 08/09/2023. The plan of care dated 08/09/2023, ordered the hospice aide frequency of visits twice a week. The clinical record contained no documented evidence of hospice aide visits for the weeks of 10/08/2023 and 10/15/2023 and no documentation of missed visits, as of the date of record review on 10/19/2023. During interview on 10/19/2023, the Chief Executive Officer /Director of Clinical Services stated the records were missing aide visit documentation because the aide was behind in entering the visit notes in the electronic medical record and agreed aide documentation was not being completed per agency policy.

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 document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed for a patient discharged and transferred to a Medicare certified facility, the agency did not ensure a copy of the discharge summary was forwarded to the receiving facility. Agency policy 9.29 Discharge Summary (Revised 2014) stated in part, "If the care of a patient is transferred to another Medicare/Medicaid certified facility, Hospice will forward, to the receiving facility; a copy of the Hospice discharge summary." Clinical Record 12: The patient elected the hospice benefit on 08/01/2022. The patient was discharged and transferred to a non-contracted facility on 12/04/2022. The clinical record contained no documented evidence that the discharge summary was forwarded to the receiving facility. During an interview on 10/20/2023, the Chief Executive Officer /Director of Clinical Services and the Administrator both reviewed the record and agreed that the agency did not ensure the discharge summary was forwarded to the receiving facility.

It is required that if a patient revokes the election of hospice care or is discharged from hospice (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 document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed of patients discharged from hospice, the agency did not ensure the hospice discharge summary was forwarded to the attending physician. Agency policy 9.29 Discharge Summary (Revised 2014) stated in part, "If a patient revokes the election of Hospice care, or is discharged from Hospice, Hospice will forward to the patient's attending physician, a copy of the Hospice discharge summary." Clinical Record 11: The patient elected the hospice benefit on 05/06/2021. The patient was discharged from hospice care on 06/24/2023 due to extended prognosis. The clinical record contained no documented evidence the discharge summary was forwarded to the patient's attending physician. During an interview on 10/20/2023, the Chief Executive Officer /Director of Clinical Services and the Administrator reviewed the finding and agreed the agency did not ensure the discharge summary was forwarded to the patient's attending physician.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. THIS IS A CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by review of agency policy, interview and review of clinical records with the Clinical Director. In 1 of 7 (14%) clinical records, there was no documented evidence that the medication list profile included an updated list of medications, as required in agency policy. Policy "Medication Reconciliation", Policy No. 8.20.1, included, in part, "At time of initial assessment, the RN will create and document a complete list of medications the patient is taking, including dose route, and frequency of medications ordered", "medications the patient is receiving will be compared to the medication list/profile [with a] medication review process to include the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, and duplicate drug therapies", and "The medication list profile will be updated with each new change of medication". Summary of findings as follows: Record #94472 - The Oxycodone frequency documented in the "IDG Comprehensive Assessment" 6/18/21 did not match the Oxycodone frequency on the medication list profile. The "IDG Comprehensive Assessment" 6/18/21 included, in part, "Oxycodone 10 mg every 6 hours PRN". The medication list profile stated, "Oxycodone 5 mg two tablets 2 times a day PRN". During interview, the Clinical Director stated "The frequency of the Oxycodone documented in the IDG on 6/18/21 does not match the medication profile".

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. The 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 IS A CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by review of clinical records with the Clinical Director and interview. In 2 of 3 (66%) applicable clinical records of patients requiring recertification, there was no documented evidence that the recertification was signed by the hospice medical director or designee 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, as required in agency policy. Agency policy titled "Certification of Terminal Illness", Policy No. 11.1.1, revised 6/2017, included, in part "The hospice medical director or designee will sign the recertification 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". Record #94472 - For recertification benefit period 9/13/21-11/11/21, there was no documented evidence that the recertification was signed by the hospice medical director or designee 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. The recertification was signed by the physician 9/19/21 and there was no documented verbal recertification order no later than two (2) calendar days after the first day of the benefit period or within fifteen (15) days before the benefit period began. The "verbal order" section of the "Certification of Terminal Illness" form was blank and there were no other verbal orders for recertification in the clinical record. During joint clinical record review, the Clinical Director stated "The physician signed the recertification on 9/19/21 and "The "Verbal Order" section of the Recertification form is blank". Record #25077 - For recertification benefit period 10/14/21-12/12/21, there was no documented evidence that the recertification was signed by the hospice medical director or designee 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. The recertification was signed by the physician 10/17/21 and there was no documented verbal recertification order no later than two (2) calendar days after the first day of the benefit period or within fifteen (15) days before the benefit period began. The "verbal order" section of the "Certification of Terminal Illness" form was blank and there were no other verbal orders for recertification in the clinical record. During joint clinical record review, the Clinical Director stated "The physician signed the recertification on 10/17/21 and "The "Verbal Order" section of the Recertification form is blank". During interview, the Clinical Director stated "The RN is assigned to enter in the verbal recertification order when they do their IDG summaries".

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes Physician orders. THIS IS A CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical records with the Clinical Director, and interview. In 2 of 7 (29%) clinical records, there was no documented evidence of physician's orders. Record #63542 - The "IDG Comprehensive Assessment" 10/22/21 included, in part, "antifungal powder applied to reddened area front of neck". There was no documented physician's order in the clinical record for antifungal powder. During clinical record review, the Clinical Director stated that she could not locate the missing physician's order for the antifungal powder in the clinical record. Record #94472 - The "IDG Comprehensive Assessment" 6/18/21 included, in part, "Oxycodone 10 mg every 6 hours PRN". There was no documented physician's order in the clinical record for Oxycodone 10 mg every 6 hours PRN. The medication list profile included an order for "Oxycodone 5 mg two tablets 2 x day PRN". During clinical record review, the Clinical Director stated that she only saw an order for the Oxycodone frequency of "2 x day PRN".