Every finding on record at Life Choice Hospice of New Mexico, LLC

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This Condition was not met as evidenced by clinical record review, document review, and interview with the Director of Clinical Services, which revealed issues with the completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to demonstrate completion of spiritual and psychosocial assessments, as part of the initial comprehensive assessment, within five (5) calendar days after the election of hospice care [HCPC.9.I/L523]; Failure of the hospice Interdisciplinary Group to ensure the comprehensive assessment included a drug profile that contained the patient's current prescription drugs [HCPC.15.I/L530]; and Failure of the hospice Interdisciplinary Group to demonstrate completion of an initial bereavement assessment [HCPC.13.I/L531]. The cumulative effect of these systemic problems has resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42CFR 484.54 Initial and Comprehensive assessment of the patient. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

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, document review, and interview. Agency policy, "Completing the Initial and Comprehensive Assessments,” stated in part, “The first comprehensive assessment for psychosocial and spiritual needs is completed not more than 5 days following the date of election. If the SW cannot complete the psychosocial portion of the first comprehensive assessment, the RN will use the Coordination Note in the EMR labeled Psychosocial Assessment Completed by the RN. If the Spiritual Counselor cannot complete the spiritual portion of the first comprehensive assessment, the RN will use the Coordination Note in the EMR labeled Spiritual Assessment Completed by the RN." In 8 of 19 (42%) clinical records reviewed, the hospice did not ensure the initial comprehensive assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 1: The patient elected hospice care on 4/25/2023. There was no documented evidence an initial psychosocial assessment was completed or reason documented for the delay of the assessment. The initial spiritual assessment was completed on 6/20/2023, 56 days after the patient's election of hospice care. There was no reason documented for the delay of the assessment. Clinical Record 6: The patient elected hospice care on 2/25/2023. There was no evidence an initial psychosocial assessment was completed or reason documented for the assessment delay. Clinical Record 10: The patient elected hospice care on 1/13/2023. The initial psychosocial assessment was completed on 1/23/2023, ten (10) days after the patient's election of hospice care. There was no reason documented for the assessment delay. Clinical Record 13: The patient elected hospice care on 9/27/2022. There was no evidence an initial psychosocial assessment was completed or reason documented for the assessment delay. Clinical Record 15: The patient elected hospice care on 7/20/2022. There was no documented evidence an initial spiritual assessment was completed or reason documented for the assessment delay. Clinical Record 17: The patient elected hospice care on 12/14/2022. The initial psychosocial assessment was completed on 12/20/2022, six (6) days after the patient's election of hospice care. The initial spiritual assessment was completed on 12/21/2022, seven (7) days after the patient's election of hospice care. There was no reason documented for the delay of the assessments. Clinical Record 18: The patient elected hospice care on 11/22/2022. The initial psychosocial assessment was completed on 11/29/2022, seven (7) days after the patient's election of hospice care. There was no reason documented for the assessment delay. Clinical Record 19: The patient elected hospice care on 7/13/2022. There was no evidence an initial psychosocial assessment was completed or reason documented for the assessment delay. During a joint review of the record and an interview on 8/23/2023, the Director of Clinical Services agreed there was no documented evidence the initial spiritual and psychosocial assessments were completed no later than five days after the election of hospice care. The Director of Clinical Services stated, “We have identified this problem, and more education is needed.”

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 medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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 standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the hospice did not ensure that the drug profile was updated when new medications were added, or changes were made to existing medications. Clinical Record 13: The patient’s date of election was 9/27/2022. The Registered Nurse (RN) visit note dated 9/28/2022 documented "Morphine increased to 7mg/hr." The RN visit note dated 9/29/2022 documented, "Morphine increased to 8mg/hr." The medication profile documented" Morphine 10mg/ml 5mg/hr with a start date of 9/27/2022." A review of the clinical record revealed no documented evidence the medication profile was updated to include Morphine 7mg/hr and 8mg/hr. Clinical Record 15: The patient’s date of election was 7/20/2022. The RN visit note dated 12/2/2022 documented new orders for "Prednisone 20mg daily x 5 days." A clinical record review revealed no documented evidence the medication profile was updated to include "Prednisone 20mg x 5 days." Clinical Record 18: The patient’s date of election was 11/22/2022. The RN visit note dated 11/22/2022 documented the patient was using "5 ½ liters of oxygen." The RN visit note dated 11/29/2022 documented, "pt (patient) observed sitting on her bed on a non-rebreather mask at 20 liters of oxygen." A clinical record review revealed no documented evidence the medication profile was updated to include the change in the oxygen liter flow. During a joint review of the record and an interview on 8/23/2023, the Director of Clinical Services agreed there was no documented evidence that the medications were updated to the medication profile.

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, document review, and interview. Agency policy, "Completing the Initial and Comprehensive Assessments,” stated in part, “An initial bereavement risk assessment is included in the assessments completed in the patient's first 5 days of care. Can be completed by the RN, social worker, or spiritual counselor as part of the first comprehensive assessment." In 4 of 19 (21%) clinical records reviewed, the hospice did not ensure an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 4: The patient’s date of election was 6/3/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 10: The patient’s date of election was 1/13/2023. The initial bereavement assessment was completed on 2/20/2023, with 38 days outstanding. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 16: The patient’s date of election was 7/26/2022. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 17: The patient’s date of election was 12/14/2022. The initial bereavement assessment was completed on 12/21/2022, with seven (7) days outstanding. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. During a joint review of the record and an interview on 8/24/2023, the Director of Clinical Services agreed there was no documented evidence the initial bereavement assessments were completed no later than five days after the election of hospice care.

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), the patient or patient representative, the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the hospice did not ensure hospice care and services were provided to patients and families as ordered. Agency policy, "Respite Care,” stated in part, “The visit frequency for the patient would change to a daily visit while the patient is in respite. A member of the hospice IDG (not including the hospice aide or a volunteer) makes a daily visit to ensure the plan of care remains sufficient to support the patient’s functional, physical, and emotional needs while in the respite environment.” Clinical Record 1: The patient elected hospice care on 4/25/2023. The physician’s order effective 6/18/2023 ordered "SN 3wk5." During the week of 7/9/2023 through 7/15/2023, a nursing visit was documented on 7/12/2023. A missed visit was documented on 7/10/2023. There was no evidence of a third skilled nursing visit or evidence of a documented missed visit. Clinical Record 5: The patient elected hospice care on 9/19/2022. The physician’s order effective 3/26/2023 documented "skilled nursing 1wk7." During the week of 4/2/2023 through 4/8/2023, there was no documented evidence of a skilled nursing visit or evidence of a documented missed visit. Clinical Record 7: The patient elected hospice care on 12/4/2021. The plan of care on1/24/2023 ordered "skilled nurse 1wk1, 2wk8." During the week of 2/26/2023 through 3/4/2023, a nursing visit was documented on 2/27/2023. There was no documented evidence of a second skilled nursing visit or evidence of a documented missed visit. During the week of 3/5/2023 through 3/11/2023, there was no evidence of a skilled nursing visit or evidence of a documented missed visit. During the week of 3/12/2023 through 3/18/2023, a nursing visit was documented on 3/13/2023. There was no documented evidence of a second skilled nursing visit or evidence of a documented missed visit. Clinical Record 8: The patient elected hospice care on 2/10/2023. The physician order effective 3/1/23 documented "SW 3m1, 1m1." There was no evidence of a social worker visit from 4/1/2023 through 4/30/2023 or evidence of a documented missed visit. Clinical Record 10: The patient elected hospice care on 1/13/2023. The physician’s order entered on 3/31/2023, effective 3/23/2023, ordered respite level of care for 3/23/2023. The social worker's note on 3/22/2023 documented, "This client will be admitted to nursing home on Thursday, March 23, 2023, he will go for 5 days of respite, the client will return home Tuesday, March 28." The social worker's note on 3/23/2023 documented a visit to the patient's home. There was no evidence a member of the IDG made a daily visit to the patient during the respite stay at the nursing facility from 3/23/2023 through 3/26/2023 per the agency policy. A RN visit was documented on the last day of the respite stay, 3/27/2023. A clinical record review revealed no evidence of documented missed visits or reason for the missed visits. Clinical Record 11: The patient elected hospice care on 9/23/2022. The plan of care dated 5/21/2023 ordered "skilled nursing 1w8." During the week of 6/18/2023 through 6/24/2023, there was no evidence of a skilled nursing visit or evidence of a documented missed visit. Clinical Record 12: The patient elected hospice care on 12/24/2022. The physician’s order effective 2/1/2023 ordered "SW 2m1." During the month of 2/1/2023 through 2/28/2023, there was a social worker visit on 2/20/2023. There was no evidence of a second social worker visit or evidence of a documented missed visit. During a joint review of the record and an interview on 8/24/2023, the Director of Clinical Services agreed there was no documented evidence that the hospice care and services were provided as ordered.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) records reviewed, the hospice did not ensure the plan of care was individualized to include planned interventions and goals based on problems in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 4/25/2023. The primary hospice diagnosis was frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage. The Registered Nurse (RN) assessment on 4/25/2023 documented a "high fall risk, 1-2 falls in the past 3 months." The RN assessment on 6/21/2023 documented that the patient "had a non-injury fall, may have had a seizure." The RN assessment completed on 8/8/2023 documented "very unsteady on his feet and should be using a walker but refuses, so he continuously falls." The plan of care effective 4/25/2023 through 8/21/2023 did not include documentation of problems, goals, and interventions for the high fall risk. Clinical Record 6: The patient elected hospice care on 2/25/2023. The primary hospice diagnosis was end-stage heart disease. The RN assessment on 2/25/2023 documented "urinary catheter in place, 18F/10ml balloon." The RN assessment on 4/25/2023 documented foley draining. The plan of care effective 2/25/2023 through 8/22/2023 did not include documentation of problems, goals, and interventions for the Foley catheter. Clinical Record 9: The patient elected hospice care on 6/8/2023. The primary hospice diagnosis was protein-calorie malnutrition. The RN assessment completed on 8/3/2023 documented "patient continues to be concerned with constipation." The RN assessment completed on 7/27/2023 documented, "patient also states that she is constipated and has not been able to have a full bowel movement in the last week, last bowel movement known was Tuesday of last week...per patient request fleet saline enema administered, patient tolerated well, RN administered suppository as well." The plan of care effective 7/2/2023 through 8/22/2023 did not include documentation of problems, goals, and interventions for constipation. Clinical Record 10: The patient elected hospice care on 1/13/2023. The primary hospice diagnosis was end-stage liver disease. The RN assessment completed on 1/13/2023 documented "patient is a high fall risk, pain 6/10." The RN assessment completed on 1/14/2023 documented "MS Contin 15mg ER 2 times daily." The RN assessment completed on 5/4/2023 documented "3/10 pain." The RN assessment on 5/19/2023 documented "patient taking breakthrough pain meds greater than 3 times a day." The plan of care effective 1/13/2023 through 8/22/2023 did not include documentation of problems, goals, and interventions for the pain and high fall risk. Clinical Record 11: The patient elected hospice care on 9/23/2022. The primary hospice diagnosis was senile degeneration of the brain. The RN assessment completed on 9/23/2022 documented "3+ bilateral lower extremity edema, unsteady gait, fall yesterday 9/22/2022." The plan of care effective 9/23/2022 through 8/22/2023 did not include documentation of problems, goals, and interventions for the edema and fall risk. During a joint review of the record and an interview on 8/22/2023, the Director of Clinical Services agreed there was no documented evidence that the plans of care were individualized to include planned interventions and goals based on the identified problems.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed of patients that received hospice aide services, the hospice did not ensure the hospice provided services ordered by the Interdisciplinary Group. Clinical Record 5: The patient elected hospice care on 9/19/2022. The plan of care dated 9/19/2022 ordered "hospice aide 1wk1, 2wk11." During the week of 10/2/2022 through 10/8/2022, one hospice aide visit was documented on 10/4/2022. There was no evidence of a second hospice aide visit or a documented missed visit. During a joint review of the record and an interview on 8/24/2023, the Director of Clinical Services confirmed services were not provided as ordered.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care; documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, "Volunteers,” stated in part, “Volunteers can perform a variety of services for hospice patients and families which are reflected in the hospice patient’s plan of care as an intervention to support a desired outcome." In 1 of 1 (100%) clinical record review of a patient receiving volunteer visits, the hospice did not ensure a plan of care was established for volunteer services. Clinical Record 6: The patient elected hospice care on 2/25/2023. The plans of care dated 2/25/2023 through 8/24/2023 did not include documented evidence of volunteer services. The Volunteer paper visit notes documented visits completed 6/2/2023, 6/12/2023, 6/23/2023, 8/3/2023, 8/10/2023 and 8/17/2023. During a joint review of the record and an interview on 8/24/2023, the Area Executive of Clinical Operations agreed there was no documented evidence of a plan of care for volunteer services.

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: physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the hospice did not ensure the clinical record included physician orders for services and treatments provided. Clinical Record 6: The patient elected hospice care on 2/25/2023. On 6/17/2023 the physician ordered, "irrigate foley catheter 3-4 times a day or as needed with 20cc." The order did not include what to irrigate the foley with. Additionally, volunteer visits were documented on 6/2/2023, 6/12/2023, 6/23/2023, 8/3/2023, 8/10/2023 and 8/17/2023. There was no documented evidence of an order for the volunteer visits. Clinical Record 9: The patient elected hospice care on 6/8/2023. The Registered Nurse visit note dated 7/27/2023 documented "fleet saline enema and suppository administered." There was no documented evidence of an order for the enema or suppository. Clinical Record 12: The patient elected hospice care on 12/24/2022. On 2/23/2023 the physician ordered "clean wound with wound cleanser, apply dressing." The order did not include the location of the wound or frequency of wound care. During a joint review of the record and an interview on 8/23/2023, the Director of Clinical Services agreed there was no documented evidence of a physician’s order for the volunteer visits, enema, or suppository. Additionally, during an interview on 8/23/2023, the Director of Clinical Services agreed the wound order and foley irrigation orders were incomplete.

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 described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, "Discharge/Transfer/Revocation,” stated in part, “will provide a discharge summary to the receiving hospice containing: treatments, symptoms, pain management, current plan of care, latest physician's orders, other documentation facilitating continuity of care." Clinical Record 15: The patient elected hospice care on 7/20/2022 and was transferred to another hospice on 12/5/2022. There was no documented evidence that the discharge summary was forwarded to the receiving hospice. During a joint review of the record and an interview on 8/22/2023, the Director of Clinical Services agreed there was no documented evidence that the discharge summary was forwarded to the receiving hospice.

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. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, "Discharge/Transfer/Revocation,” stated in part, “will provide a discharge summary to the attending physician containing: treatments, symptoms, pain management, current plan of care, latest physician's orders, other documentation facilitating continuity of care." In 1 of 1 (100%) clinical record review of a patient who revoked the election of hospice care, the hospice did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 16: The patient elected hospice care on 7/26/2022 and revoked hospice services on 4/14/2023 to seek treatment outside the plan of care. There was no documented evidence that the discharge summary was forwarded to the patient’s attending physician. During a joint review of the record and an interview on 8/22/2023, the Director of Clinical Services agreed there was no documented evidence that the discharge summary was forwarded to the patient's attending physician.

It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice: are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation; act only within the scope of their state license or state certification or registration; [and] keep their qualifications current at all times. THIS IS A CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by personnel record review, document review, clinical record review, and interview. The hospice failed to ensure the Social Worker who provided services was licensed in accordance with state regulation [HSRM.7.D/L787]. The cumulative effect of these systemic problems has resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42CFR 484.114 Personnel Qualifications. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that a social worker has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; or a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education; or a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above; and at least one (1) year of social work experience in a health care setting. This standard was not met as evidenced by personnel record review, clinical record review, document review, and interview. 1 of 2 (50%) personnel records reviewed of employed Social Workers, the hospice did not ensure the Social Worker (SW) was licensed as required by the state regulations and the organization's job description. The state's "Requirements for Home Health Agencies" read in part, “Social worker” is a person who is licensed by the state of …. as a social worker, pursuant...". The state's article... "Social Work Practice" read in part, "License required. (Repealed effective July 1, 2022.)… Effective January 1, 1990, unless licensed to practice social work under the Social Work Practice Act ...no person shall: (1) practice as an independent social worker as defined in the Social Work Practice Act; or (2) use the title or represent himself as a licensed social worker or use any other title, abbreviation, letters, figures, signs or devices that indicate the person is licensed as a social worker." Personnel Record 9: The Social Worker (SW) was hired on 9/19/2022. The job description signed by the employee on 9/19/2022 titled "Social Worker" read in part, "State-specific requirements: licensure is required, BSW is minimum education required but must be supervised by MSW, MSW is preferred education for hospice social worker." A review of the personnel record revealed no state license. There was no documented evidence that the Social Worker was licensed by the state prior to providing care. A clinical record review revealed the unlicensed Social Worker completed visits and authenticated visit notes for Clinical Record 11, initial SW visit dated and signed 9/28/2022; Clinical Record 2, SW visit note signed and dated 8/22/2023; and Clinical 4, initial SW visit signed and dated 6/6/2023. During a joint review of the clinical records and an interview on 8/24/2023, the Director of Clinical Services stated that we are pulling the SW because she cannot work without a license. During an interview on 8/24/2023, the Area Executive of Clinical Operations agreed there was no documented evidence the social worker was licensed. 1 of 2 Sw 3 of 19 visit type ms 01 medical social worker signed sw Record 11: SOC 9/23/2022. Initial SW visit on 9/28/2022 signed SW on 9/28/2022. Record 2: Sw signed 8/22/23 in person Record 4: ms o1 initial on tc 6/6/2023