Every finding on record at Life Choice Hospice of Massachusetts, LLC

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 clinical record review and document review. Agency policy C03 "Election and Informed Consent" stated in part, "Content of hospice election statement addendum. For Hospice elections beginning on or after October 1, 2020, in the event (hospice name) determines there are conditions, items, services, or drugs that are unrelated to the individual's terminal illness and related conditions, the individual (or representative, non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement...If the patient/rep requests a copy of this information (the addendum) during the first five days of the election (that is between the date of election and day 5), then (hospice name) will provide it to the patient/rep with 5 days of the request." In 1 of 3 (33%) clinical records reviewed that the patient/family requested a non-coverage addendum, the agency did not ensure that the patient/family received the non-coverage addendum within the five (5) day time frame as per the agency's policy. Clinical Record 14: The patient elected the hospice benefit on 2/24/2024. The patient/caregiver requested a non-coverage addendum on the day of election. A joint record review of the clinical record with the Area Executive Director of Clinical Operations revealed the agency provided the document to the patient/caregiver on 03/05/2024, with ten (10) days outstanding. During an interview, the Area Executive Director of Clinical Operations stated these forms go to the Hospice Team Coordinators' workflow for completion and then back to the nurse for delivery. The week of 02/25/2024 through 03/02/2024 the Hospice Team Coordinator was on vacation and there was no one checking her workflow. This had been identified as a process improvement opportunity and the agency had scheduled meetings and trainings for a new process. Agency policy C03-Election and Informed Consent states in part, "Content of hospice election statement addendum. For Hospice elections beginning on or after October 1, 2020, in the event Compassus determines there are conditions, items, services, or drugs that are unrelated to the individual's terminal illness and related conditions, the individual (or representative, non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement." It also states in part, " If the patient/rep requests a copy of this information (the addendum) during the first five days of the election (that is between the date of election and day 5), then Compassus will provide it to the patient/rep with 5 days of the request."

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 and observation. Agency policy #C_11 "Bag Technique and Standard Precautions" stated in part, "When to use hand gel (sanitizer), 1. Before direct patient contact and after direct patient contact. 2. Before donning gloves and after removing gloves." In 1 of 4 (25%) home visits observed, the hospice did not ensure that hand hygiene was performed when indicated according to the agency's policy. Home Visit 2/Clinical Record 7: The patient elected hospice care on 01/05/2024 and resided in a skilled nursing facility (SNF). During the home visit with the Licensed Practical Nurse (LPN) [Personnel Record 5] on 03/27/2024, the LPN did not take their gloves off before using hand gel (sanitizer). The LPN sanitized their hands with the gloves on and went back to caring for the patient. The agency policy C_11 Bag Technique and Standard Precautions, states in part, "when to use hand gel (sanitizer), 1. Before direct patient contact and after direct patient contact. 2. Before donning gloves and after removing gloves."