Every finding on record at Liberty Hospice Care

It is required that during the initial assessment visit and in advance of providing care: The hospice provides the patient—or his or her representative—with verbal and written notice of the patient’s rights and responsibilities. This information is provided in a language and manner that the patient understands. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidence by review of clinical records, documents, and interview which revealed 5 of 5 (100%) clinical records did not contain evidence of documents signed by either the patient or their representative confirming that he or she received a copy of the Patient Bill of Rights and Responsibilities statement when admitted to hospice. Record #53288 – The patient was admitted to hospice on 5/11/21 and there was no evidence to confirm that the patient had signed a receipt of patient rights document at the time of admission. A document was present in the record that was produced by the EMR and contained evidence of an electronic signature with the patient’s name, but there was no evidence that the patient had accessed a system to electronically sign the document, and there was no evidence of a paper document that was hand-signed by the patient, as reported by the admitting nurse. Record #23735 – The patient was admitted to hospice on 8/11/21 and there was no evidence to confirm that the patient had signed a receipt of patient rights document at the time of admission. A document was present in the record that was produced by the EMR and contained evidence of an electronic signature with the patient’s name, but there was no evidence that the patient had accessed a system to electronically sign the document, and there was no evidence of a paper document that was hand-signed by the patient, as reported by the admitting nurse. Record #79466 – The patient was admitted to hospice on 8/18/21 and there was no evidence to confirm that the patient had signed a receipt of patient rights document at the time of admission. A document was present in the record that was produced by the EMR and contained evidence of an electronic signature with the patient’s name, but there was no evidence that the patient had accessed a system to electronically sign the document, and there was no evidence of a paper document that was hand-signed by the patient, as reported by the admitting nurse. Record #17628 – The patient was admitted to hospice on 8/24/21 and there was no evidence to confirm that the patient had signed a receipt of patient rights document at the time of admission. A document was present in the record that was produced by the EMR and contained evidence of an electronic signature with the patient’s name, but there was no evidence that the patient had accessed a system to electronically sign the document, and there was no evidence of a paper document that was hand-signed by the patient, as reported by the admitting nurse. Record #16311 – The patient was admitted to hospice on 9/9/21 and there was no evidence to confirm that the patient had signed a receipt of patient rights document at the time of admission. A document was present in the record that was produced by the EMR and contained evidence of an electronic signature with the patient’s name, but there was no evidence that the patient had accessed a system to electronically sign the document, and there was no evidence of a paper document that was hand-signed by the patient, as reported by the admitting nurse. During interview on 11/30/21 with the consultant for the agency, they stated that the agency has chosen to "automate" paper clinical documents, including the receipt of patient rights statement, so they could be completed, stored, and signed electronically. The consultant stated that she was “not sure of the process” utilized to obtain an electronic signature from the patient, but the patients could electronically sign any documents requiring their signature. During 3 of 3 (100%) home visit observations [Records: #79466, #17628, and #16311] conducted on 12/1/21, review of the patients’ in-home folders revealed they contained copies of admission documents, including the receipt of patient rights document that contained an electronic signature with the patient’s name. During the home visits, interview with the RN (Record #37441, Date of Hire 3/30/21), who was responsible for admitting all patients that have received service from the agency, she revealed that all admission documents, including the receipt of patient rights, were presented to the patients and their representatives on paper and were all signed "with a pen" by the patient. She stated there was currently no system in place for the patient to sign the forms electronically during the admission visit. After the admission visit was completed, the RN stated that she transports the signed paper documents to the office so they can be placed in the patients' records. During a subsequent interview with the hospice Clinical Manager/Alternate Administrator and the consultant, conducted after completion of the home visits, a request was made to review the paper receipt of patient rights documents that were hand-signed by the patients at the time of admission to confirm the patients had actually signed the form. The consultant stated, “There is nothing else available.” The consultant also stated that if there was a way to verify that the electronic signatures present on the automated forms had been completed by the patients or their representative, she was unaware of it.

It is required that the written Patient Bill of Rights includes the right to: receive information about the services covered under the hospice benefit. This standard was not met as evidenced by review of clinical records and interview which revealed 5 of 5 (100%) clinical records did not include information that patients were notified of their right to receive information regarding the medications and services that were covered under the hospice benefit and those that were not, as required by the CMS Hospice Election Statement Addendum, effective October 1, 2020, "Patient Notification of Non-covered Items, Services, and Drugs" [Records: #53288 (admitted 5/11/21, revoked 8/3/21); #23735 (admitted 8/11/21, revoked 11/3/21); #79466 (admitted 8/18/21); #17628 (admitted 8/24/21); #16311 (admitted 9/9/21)]. The addendum requires hospice patients to be notified in writing of those conditions, items, services, and drugs not covered by the hospice because the hospice has determined they are unrelated to the patient’s terminal illness and related conditions. If the patient or representative request this notification on the effective date of the hospice election (that is, on the start date of hospice care), the hospice must provide this form within 5 days. If the form is requested at any point after the start date of hospice care, the hospice must provide the patient (or representative) this form within 3 days. As a Medicare beneficiary, the patient (or representative) has the right to contact the Medicare Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) to request for Immediate Advocacy if the patient (or representative) disagree with the decision of the hospice agency on items not covered because the hospice has determined they are unrelated to the terminal illness and related conditions. During interview on 12/1/21, the agency’s hired consultant stated that neither she nor the agency Administrator or clinical leadership staff were aware that the "Patient Notification of Non-covered Items, Services, and Drugs" was to be provided as an addendum to the written Patient Bill of Rights before the initiation of care, as of October 1, 2020. The consultant stated that this information was not provided to any patients admitted to the agency from the time of hospice state licensure review on 5/4/21, to the present time. up to the time of the exit conference.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s: Overall management and operation; and provision of care and services. THIS IS A CMS CONDITION LEVEL CITATION. This condition of participation was not met as evidenced by clinical record review, document review and interview, which revealed the absence of oversight by the Administrator/Owner and the Director of Professional Clinical Services/Alternate Administrator to ensure overall management of daily operations in the provision of patient care and services. This lack of process structure and oversight resulted in the following citations: HCDT. 40.I/L684 related to 2 of 2 (100%) applicable records reviewed were missing discharge summary information to assist with the coordination of care for patients who revoked hospice services; HPFC.2.2/L519 related to 5 of 5 (100%) records did not contain evidence that patients were provided with notification and information related to their right to receive information regarding the medications and services that would and would not be covered under hospice; HPEC.3.I/L504 and HSIM.3.I/L673 related to 5 of 5 (100%) records for each citation did not contain evidence of a process and system that confirmed documentation of patients' signatures for review and receipt of patient rights information, admission consent, and election of hospice services; HSIM.4.I/L679 related to 5 of 5 (100%) records contained copies of documents with electronic patient signatures that could not be authenticated as signed by the patients; and HIPC.9.I related to 9 of 9 (100%) personnel health records were missing evidence of compliance with TB testing requirements described in agency policy and state requirements. Interviews conducted during the 3-day site visit review did not include participation of the Administrator/Owner, and limited participation of the Director of Professional Services/Alternate Administrator. During interview with Director of Professional Services/Alternate Administrator regarding operational processes and her role in providing oversight of hospice operations, she stated that she "was not sure" what the extent of her role would be moving forward. During interview with the agency's hired consultant, she reported that the Administrator preferred to have the consultant directly coordinate the site visit review and respond to all questions. The cumulative effect and scope of these deficiencies could negatively impact the agency's ability to provide patients with safe, coordinated, quality care that informs and meets the needs of patients, families, and caregivers for the palliation and management of the patients' terminal illness and related conditions.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by review of 5 of 5 (100%) clinical records during which revealed the records did not contain copies of the notice of patient rights and the hospice election statement that were signed by the patients during admission to hospice. Record #53288 – The patient was admitted to hospice on 5/11/21 and revoked hospice on 8/3/21. The clinical record was reviewed and there was no evidence of the copy of the hospice election statement and the notice of patient rights documents that were signed by the patient at the time of hospice admission. The documents present in the record were produced by the EMR and contained evidence of an electronic signature of the patient but there was no evidence that the patient had accessed a system to electronically sign the documents. Record #23735 – The patient was admitted to hospice on 8/11/21 and revoked hospice on 11/3/21. The clinical record was reviewed and there was no evidence of the copy of the hospice election statement and the notice of patient rights documents that were signed by the patient at the time of hospice admission. The documents present in the record were produced by the EMR and contained evidence of an electronic signature of the patient but there was no evidence that the patient had accessed a system to electronically sign the documents. Record #79466 – The patient was admitted to hospice on 8/18/21. The clinical record was reviewed and there was no evidence of the copy of the hospice election statement and the notice of patient rights documents that were signed by the patient at the time of hospice admission. The documents present in the record were produced by the EMR and contained evidence of an electronic signature of the patient but there was no evidence that the patient had accessed a system to electronically sign the documents. Record #17628 – The patient was admitted to hospice on 8/24/21. The clinical record was reviewed and there was no evidence of the copy of the hospice election statement and the notice of patient rights documents that were signed by the patient at the time of hospice admission. The documents present in the record were produced by the EMR and contained evidence of an electronic signature of the patient but there was no evidence that the patient had accessed a system to electronically sign the documents. Record #16311 – The patient was admitted to hospice on 9/9/21. The clinical record was reviewed and there was no evidence of the copy of the hospice election statement and the notice of patient rights documents that were signed by the patient at the time of hospice admission. The documents present in the record were produced by the EMR and contained evidence of an electronic signature of the patient but there was no evidence that the patient had accessed a system to electronically sign the documents. During interview on 11/30/21 with the consultant for the agency, they stated that the agency has chosen to "automate" paper clinical documents, including consents and benefit of election statements, so they could be completed, stored, and signed electronically. The consultant stated that she was “not sure of the process” utilized to obtain an electronic signature from the patient, but the patients could electronically sign any documents requiring their signature. During 3 of 3 (100%) home visit observations [Records: #79466, #17628, and #16311] conducted on 12/1/21, review of the patients’ in-home folders revealed they contained copies of admission documents, including the admission consent, hospice benefit election, and receipt of patient rights documents that contained documentation of an electronic signature with the patient’s name. During the home visits, interview with the RN (Record #37441, Date of Hire 3/30/21), who was responsible for admitting all patients that have received service from the agency, she revealed that all admission, consent, and benefit of election documents were presented to the patients and their representatives on paper and were all signed "with a pen" by the patient. She stated there was currently no system in place for the patient to sign the forms electronically during the admission visit. After the admission visit was completed, the RN stated that she transports the signed paper documents to the office so they can be placed in the patients' records. During a subsequent interview with the hospice Clinical Manager/Alternate Administrator and the consultant, conducted after completion of the home visits, a request was made to review the paper admission documents signed by the patients to confirm the patients had actually signed the documents. The consultant stated, “There is nothing else available.” The consultant also stated that if there was a way to verify that the electronic signatures present on the automated forms had been completed by the patients or their representative, she was unaware of it.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. This standard was not met as evidenced by review of clinical records and interviews which revealed 5 of 5 (100%) records contained copies of documents with electronic patient signatures that could not be authenticated as signed by the patients [Records: #53288, #23735, #79466, #17628, #16311]. Each clinical reviewed contained copies of documents produced by the agency's EMR that were notated with the name of the patient in an area designated for an electronic signature. However, there was no documented evidence that the patient had accessed a system to electronically sign the documents. During interview on 12l1l21 with the hospice nurse (Record #37441) who completed all of the patient admissions, they stated that patients were presented with paper copies of their hospice election, admission consent, and receipt of patient rights at the time of admission, and all documents were hand-signed "with a pen". The signed documents were then submitted to the office for inclusion in the clinical record. The nurse also reported that the hospice did not currently have a system in place for the patient to sign the forms electronically during the admission visit. During interviews with the hospice Clinical Manager/Alternate Administrator and the consultant on 11/30/21 and 12/1/21, they were not able to describe the process used by the agency to obtain the patients’ electronic signatures. When a request was made to review the paper admission documents signed by the patients to confirm the patients had actually signed the original documents, the consultant stated, “There is nothing else available.” The consultant also stated that if there was a way to verify that the electronic signatures present on the automated forms had been completed by the patients or their representative, she was unaware of it.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by review of documents and clinical records which revealed that 2 of 2 (100%) discharged records did not include a written summary of the patient's stay, including treatments, symptoms, and pain management; documentation that will assist in post-discharge continuity of care, and a description of services provided and ongoing needs that cannot be met, as described in agency policy. Record #23735 - The patient was admitted on 8/11/21 with a diagnosis of End Stage Hepatic Failure, and revoked hospice on 11/3/21. The documented discharge summary in the patient’s record included only a statement that the patient was “revoking services to seek aggressive treatment” and that “home health services were offered”. The discharge summary template contained the following sections that were blank: Condition on discharge; Care Summary; Goal Outcomes; Resources needed ongoing; Number of visits by discipline. Record #53288 - The patient was admitted on 5/11/21 with a diagnosis of CA of Breast, and revoked hospice on 8/3/21. The documented discharge summary in the patient’s record included only a statement that the patient was “revoking services to seek aggressive treatment” and that “home health services were offered”. The discharge summary template contained the following sections that were blank: Condition on discharge; Care Summary; Goal Outcomes; Resources needed ongoing; Number of visits by discipline. Agency policy, titled "Discharge Summary", stated in part: "The Hospice discharge summary will include: a summary of the patient's stay including treatments, symptoms, and pain management;... any other documentation that will assist in post-discharge continuity of care;... a brief description of services provided and ongoing needs that cannot be met."