Every finding on record at Lilycare of New Mexico LLC

It is required that the hospice implements emergency preparedness (EP) policies and procedures. The policies and procedures address development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment, the documented discussion of the plan provided to the patient/family and maintained by the hospice, follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency. This standard was not met as evidenced by clinical record review and interview. In 10 of 12 (83%) clinical records reviewed, the agency did not ensue that the documented discussion of the emergency plan was provided to the patient/family. Clinical Record 1: The patient elected the hospice benefit on 5/3/23. Review of the clinical record for the benefit period dated 5/3/23 to 7/31/23, lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. Clinical Record 4: The patient elected the hospice benefit on 5/4/23. The clinical record lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. Clinical Record 5: The patient elected the hospice benefit on 5/5/23. Review of the clinical record for the benefit period dated 5/5/23 to 6/14/23, lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. Clinical Record 6: The patient elected the hospice benefit on 7/12/23. The clinical record lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. Clinical Record 7: The patient elected the hospice benefit on 4/25/23. The clinical record lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. Clinical Record 8: The patient elected the hospice benefit on 3/30/23. Review of the clinical record for the benefit period dated 3/30/23 to 4/26/23, lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. Clinical Record 9: The patient elected the hospice benefit on 5/17/23. Review of the clinical record for the benefit period dated 5/17/23 to 5/23/23, lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. Clinical Record 10: The patient elected the hospice benefit on 4/7/23. Review of the clinical record for the benefit period dated 4/7/23 to 4/12/23, lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. Clinical Record 11: The patient elected the hospice benefit on 6/1/23. Review of the clinical record for the benefit period dated 6/1/23 to 7/5/23, lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, and or family/caregiver. Clinical Record 12: The patient elected the hospice benefit on5/15/23. Review of the clinical record for the benefit period dated 5/14/23 to 6/15/23, lacked documented evidence that the documented discussion of the individual emergency plan developed for the patient was provided to the patient, family and/or caregiver. During individual interviews with the Clinical Director and the Executive Director conducted on 7/26/23, they both verified in records 1, 4, 5, 6, 7, 8, 9, 10, 11 and 12 the documented discussion of the individual emergency plan developed for the patient had not been provided to the patient, family and/or caregiver. I

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 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, document review and interview. In 2 of 12 (17%) clinical records reviewed, the agency did not ensure that the medication profile included all current prescription drugs and was updated per agency policy. Agency policy titled Medication Profile, Policy No. 2-004, dated November 2020, stated in part, "Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new or discontinued medications." Clinical Record 7: The patient elected the hospice benefit on 4/25/23. The registered nurse (RN) completed a comprehensive assessment on 4/25/23 and documented, "patient utilizes albuterol inhaler and neb. (nebulizer) tx. (treatment)". The medication profile included in the comprehensive assessment did not include albuterol or nebulizer treatments as identified by the RN. Clinical Record 8: The patient elected the hospice benefit on 3/30/23. The RN completed the comprehensive assessment dated 4/4/23 which included a new physician's order that stated, "Work to open left hand and gently wash hand. Dry Thoroughly. Apply anti-fungal powder as needed for s/s (signs and symptoms) of yeast and contact (hospice agency) case manager." The medication profile included in the comprehensive assessment did not include an "antifungal powder" as ordered by the physician. During an interview and joint clinical records review on 7/26/23, the Clinical Director verified in records 7 and 8 the drug profiles did not include all the patient's prescription medications as identified by the RN in the comprehensive assessment.

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 is a continuing Required Action. This standard was not met as evidenced by clinical record review and interview. In 4 of 12 (33%) clinical records reviewed, the agency did not ensure the patient’s individualized written plan of care reflected patient and family goals, and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 7: The patient elected the hospice benefit on 4/25/23 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the clinical record revealed the Registered Nurse (RN) completed the comprehensive assessment on 4/25/23 and documented, “Pt [patient] is on O2 [oxygen], 3LPM [liters per minute] via NC [nasal cannula] and utilizes albuterol inhaler and neb [nebulizer] tx [treatment]. She is belly breathing with dyspnea at rest and raspy voice”. The plan of care (POC) for the benefit period dated 4/25/23 to 4/28/23, lacked evidence of any problems, goals or interventions to address the patient's respiratory symptoms. Clinical Record 9: The patient elected the hospice benefit on 5/17/23. Review of the clinical record revealed the comprehensive assessment was completed by the RN on 5/17/23. The RN documented the patient had a diagnosis, of "Epilepsy, unsp [unspecified], not intractable" and medication orders for "levetiracetam 100mg/ml 7.5ml oral solution 2 times daily". The POC for the benefit period dated 5/17/23 to 5/23/23 lacked evidence of any problems, goals or interventions to address seizure precautions or safety measures. Clinical Record 10: The patient elected the hospice benefit on 4/7/23 with a terminal diagnosis of congestive heart failure (CHF). Review of the clinical record revealed the RN completed the comprehensive assessment on 4/7/23. The RN documented in the respiratory assessment, “abnormal breath sounds, dyspnea on exertion, dyspnea at rest, use of accessory muscles" and in the cardiovascular assessment “orthopnea, edema, 3+ edema to lower right and left extremity/ankle”. The POC for the benefit period dated, 4/7/23 to 4/12/23 lacked evidence of any problems, goals or interventions to address the patient's cardiac or respiratory symptoms. Clinical Record 11: The patient elected the hospice benefit on 6/1/23. Review of the clinical record revealed the comprehensive assessment was completed by the RN on 6/1/23. The RN documented “C/O [compliant of] SOB [shortness of breath] and is on O2LPM via N/C to maintain sats [oxygen saturation] above 90%”. The POC for the benefit period dated 6/1/23 to 7/5/23, lacked evidence of any problems, goals or interventions to address the patient's respiratory symptoms. An interview and joint clinical record review was conducted with the Clinical Director on 7/26/23. In review of clinical records 7, 9, 10 and 11 the Clinical Director verified that the written plans of care for these patients did not include interventions to address all problems identified in the comprehensive assessments and they should have.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; Demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years with more frequent training if there is a significant update of EP policies and procedures; A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and Documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview and personnel record review. 7 of 7 (100%) personnel records reviewed revealed the hospice did not ensure that new hospice employees and those providing services under arrangement, received initial training in EP policies and procedures consistent with their expected roles. Agency Policy, “Emergency Management Plan,” stated in part, “Training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable.” Personnel Record 1 (Executive Director): Hire date 10/14/2022. There was no documented evidence in the personnel file that initial training in emergency preparedness policies and procedures was completed upon hire. Personnel Record 2 (Clinical Director/Registered Nurse Case Manager): Hire date 4/13/2023. There was no documented evidence in the personnel file that initial training in emergency preparedness policies and procedures was completed upon hire. Personnel Record 3 (Hospice Medical Director): Hire date 3/13/2023. There was no documented evidence in the personnel file that initial training in emergency preparedness policies and procedures was completed upon hire. Personnel Record 4 (Social Worker): Hire date 4/6/20233. There was no documented evidence in the personnel file that initial training in emergency preparedness policies and procedures was completed upon hire. Personnel Record 5 (Spiritual Care Counselor): Hire date 2/3/2023. There was no documented evidence in the personnel file that initial training in emergency preparedness policies and procedures was completed upon hire. Personnel Record 6 (Hospice Aide): Hire date 3/1/2023. There was no documented evidence in the personnel file that initial training in emergency preparedness policies and procedures was completed upon hire. Personnel Record 7 (Business Office Manager): Hire date 2/10/2023. There was no documented evidence in the personnel file that initial training in emergency preparedness policies and procedures was completed upon hire. The Executive Director was interviewed on 5/23/2023 and agreed, there was no documented evidence of training in emergency preparedness policies and procedures in the records identified. Additionally, during an interview on 5/23/2023, the Executive Director stated, “we do not currently have emergency preparedness training available to staff but are looking into programs and will be implementing it.” Agency policy, “Emergency Management Plan,” stated in part, “training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable.” Record 1 (Executive Director): hire date 10/14/2022. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 2 (Clinical Director/Registered Nurse Case Manager): hire date 4/13/2023. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 3 (Hospice Medical Director): hire date 3/13/2023. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 4 (Social Worker): hire date 4/6/20233. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 5 (Spiritual Care Counselor): hire date 2/3/2023. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 6 (Hospice Aide): hire date 3/1/2023. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 7 (Business Office Manager): hire date 2/10/2023. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. The Executive Director was interviewed on 5/23/2023 and agreed, there was no documented evidence of training in emergency preparedness policies and procedures in the records identified. Additionally, during an interview on 5/23/2023, the Executive Director stated, “we do not currently have emergency preparedness training available to staff but are looking into programs and will be implementing it.”

It is required that per policy and procedure, the hospice responds to alleged violations involving anyone working on the hospice’s behalf by ensuring that verified violations are reported to the state and local bodies having jurisdiction (including the State Survey and Certification Agency) within five (5) working days of becoming aware of the violation. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by clinical record review, document review and interview. 1 of 8 (100%) clinical records reviewed revealed the hospice failed to ensure that the patients' rights were not violated, as evidenced by failure to report an allegation in a skilled nursing facility. Agency Policy, "Assessment of Possible Abuse/Neglect,” stated in part, “...any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor. The clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident.” The Executive Director will submit reports to the proper authorities. Addendum 3-004.A Examples of specific events or occurrences that must be reported: Patient endangerment: Suspected abuse by family/caregiver. Note: for all above, notification to the state Elder-at-Risk program and/or Adult or Child Protective Services must be made by mandated reporters, per program requirements.” Agency Policy, “Incident Reporting,” stated in part, “Notification to State DOH. Adult Protective Services must be made by mandated reports, per program requirements.” Clinical Record 2: The patient’s date of hospice election was 5/3/2023. The hospice aide client coordination note report on 5/15/2023 documented the patient was tearful and stated he was being abused by CNA team that works in the evening, patient stated an incident happened the evening before, the team was rough with him while changing his brief, patient stated the CNA team knocked his knee into the wall causing his skin to tear, CNA observed damage to right knee. Pt stated he expressed his frustration to the CNA team and their response was to shut up or else next time it will be worse. The social worker client coordination note report on 5/16/2023 documented the patient does want to be moved to a new room due to recent allegations of abuse by facility staff. There was no documented evidence that the incident was reported to Adult Protective Services or state and local agencies. There was no documented evidence the hospice reported the allegation of patient abuse to the state Department of Health within 5 days of becoming aware. The hospice aide was interviewed on 5/23/2023 and stated, “I only reported it to my supervisor.” The social worker was interviewed on 5/23/2023 and stated, “I reported it to the facility social services director,” and confirmed the facility did not report the allegation of abuse to Adult Protective Services or to the state Department of Health. The Clinical Director was interviewed on 5/23/2023 and stated she did not report the allegation of abuse to Adult Protective Services or to the state Department of Health. The Executive Director was interviewed on 5/23/2023 and stated, “I reported it to the facility Administrator,” The Executive Director stated she did not report the allegation of abuse to Adult Protective Services or to the state Department of Health. The cumulative effect of this deficiency could negatively impact the patient's ability to safely receive hospice benefits and palliation and management of the terminal illness and related conditions in an environment free from abuse. Agency policy, "Assessment of possible abuse/neglect,” stated in part, “any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor. The clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident.” The Executive Director will submit reports to the proper authorities. Addendum 3-004.A Examples of specific events or occurrences that must be reported: Patient endangerment: Suspected abuse by family/caregiver. Note: for all above, notification to the state Elder-at-Risk program and/or Adult or Child Protective Services must be made by mandated reporters, per program requirements.” Agency policy, “Incident reporting,” stated in part, “Notification to NM DOH. Adult Protective Services must be made by mandated reports, per program requirements.” Record 2: The patient’s date of election was 5/3/2023. The hospice aide client coordination note report on 5/15/2023 documented patient was tearful and stated he was being abused by CNA team that works in the evening, patient stated an incident happened the evening before, the team was rough with him while changing his brief, patient stated the CNA team knocked his knee into the wall causing his skin to tear, CNA observed damage to right knee. Pt stated he expressed his frustration to the CNA team and their response was to shut up or else next time it will be worse.” The social worker client coordination note report on 5/16/2023 documented patient does want to be moved to a new room due to recent allegations of abuse by facility staff. There was no documented evidence that the incident was reported to Adult Protective Services. There was no documented evidence the hospice notified the State of New Mexico Department of Health within 5 days. The hospice aide was interviewed on 5/23/2023 and stated, “I only reported it to my supervisor.” The hospice aide stated she did not report the allegation of abuse to Adult Protective Services. The social worker was interviewed on 5/23/2023 and stated, “I reported it to the facility social services director,” and confirmed they did not report the allegation of abuse to Adult Protective Services or to the State of New Mexico Department of Health. The Clinical Director was interviewed on 5/23/2023 and stated she did not report the allegation of abuse to Adult Protective Services or to the State of New Mexico Department of Health. The Executive Director was interviewed on 5/23/2023 and stated, “I reported it to the facility Administrator,” The Executive Director stated she did not report the allegation of abuse to Adult Protective Services or to the State of New Mexico Department of Health.

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 clinical record review and interview. 3 of 8 (38%) clinical records reviewed revealed the hospice did not ensure the plan of care was individualized to include planned interventions based on problems in the initial and updated comprehensive assessments with patient and family goals. Record 1: The patient’s date of hospice election was 5/5/2023. The primary hospice diagnosis was congestive heart failure. The registered nurse assessment on 5/5/2023 revealed painful breathing, dyspnea on exertion, dyspnea at rest, dyspnea significantly affects the patient, dyspnea 6/10, 90% on 4L oxygen. The plan of care was reviewed 5/5/2023-5/23/2023. There was no documented evidence that the plan of care included a patient and family goal and planned interventions for the dyspnea. Record 2: The patient’s date of hospice election was 5/3/2023. The primary hospice diagnosis was Parkinson’s disease with an additional diagnosis of pain, unspecified. The registered nurse assessment on 5/3/2023 revealed pain 3/10. The medication profile revealed Tizanidine 2mg every 8 hours prn pain, Lidocaine pain relief 4% topical patch every 12 hours prn pain, Acetaminophen 325mg 2 tab every 4 hours prn pain. The plan of care was reviewed 5/3/2023-5/23/2023. There was no documented evidence that the plan of care included a patient and family goal and planned interventions for the pain. Record 3: The patient’s date of election was 5/17/2023. The primary hospice diagnosis was chronic obstructive pulmonary disease. The registered nurse assessment on 5/17/2023 revealed 4+ edema to BLLE, 4+ edema to left hand, abnormal breath sounds, dyspnea at rest, dyspnea significantly affects the patient, dyspnea 4/10, 93% on 4L oxygen. The plan of care was reviewed 5/17/2023-5/23/2023. There was no documented evidence that the plan of care included a patient and family goal and planned interventions for dyspnea or edema. The Clinical Director was interviewed on 5/23/2023 and agreed, there was no documented evidence that the plans of care identified included a patient and family goal and planned interventions for the problems identified. Record 1: The patient’s date of election was 5/5/2023. The primary hospice diagnosis was congestive heart failure. The registered nurse assessment on 5/5/2023 revealed painful breathing, dyspnea on exertion, dyspnea at rest, dyspnea significantly affects the patient, dyspnea 6/10, 90% on 4L oxygen. The plan of care was reviewed 5/5/2023-5/23/2023. There was no documented evidence that the plan of care included a patient and family goal and planned interventions for the dyspnea. Record 2: The patient’s date of election was 5/3/2023. The primary hospice diagnosis was Parkinson’s disease with an additional diagnosis of pain, unspecified. The registered nurse assessment on 5/3/2023 revealed pain 3/10. The medication profile revealed Tizanidine 2mg every 8 hours prn pain, Lidocaine pain relief 4% topical patch every 12 hours prn pain, Acetaminophen 325mg 2 tab every 4 hours prn pain. The plan of care was reviewed 5/3/2023-5/23/2023. There was no documented evidence that the plan of care included a patient and family goal and planned interventions for the pain. Record 3: The patient’s date of election was 5/17/2023. The primary hospice diagnosis was chronic obstructive pulmonary disease. The registered nurse assessment on 5/17/2023 revealed 4+ edema to BLLE, 4+ edema to left hand, abnormal breath sounds, dyspnea at rest, dyspnea significantly affects the patient, dyspnea 4/10, 93% on 4L oxygen. The plan of care was reviewed 5/17/2023-5/23/2023. There was no documented evidence that the plan of care included a patient and family goal and planned interventions for dyspnea or edema. The Clinical Director was interviewed on 5/23/2023 and agreed, there was no documented evidence that the plans of care identified included a patient and family goal and planned interventions for the problems identified.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record review, personnel record review and interview with the Clinical Director which revealed issues with hospice aide services in the following areas: Failed to ensure hospice aide services were provided as ordered by the IDG and included in the plan of care [HCDT.16.I/L626]; Failed to ensure that the hospice aide notified the registered nurse (RN) when aide services were not provided as ordered [HCDT.18.I/L628]; and Failed to ensure the hospice aide demonstrated required competencies prior to providing care to hospice patients [HSRM.9.I/L615]. The cumulative effect and scope of these deficiencies could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of four (4) training and competency evaluations programs AND the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program AND the hospice maintains documentation that each hospice aide has met the requirements. Option 2 : Hospice Aide Training and Competency Evaluation - A qualified hospice aide has successfully completed a competency evaluation program that: evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: reading and recording temperature, pulse, and respiration; bed bath; sponge, tub, and shower bath; hair shampoo; nail and skin care; toileting and elimination; and normal range of motion and positioning. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 1 (100%) personnel record of the hospice aide reviewed, revealed the hospice did not ensure that a skills competency assessment was completed upon hire before services were provided by the aide. Personnel Record 6 (Hospice Aide): Hire date 3/1/2023. A skills competency was completed by the RN on 3/29/2023 that included: ambulate with gait belt, sit to stand transfers, stand pivot transfers and sliding board transfers. There was no documented evidence that an RN observed competency of skills in the following areas: reading and recording temperature, pulse, and respiration, bed bath, sponge bath, shower bath, hair shampoo, nail and skin care, oral hygiene, toileting and elimination, normal range of motion and positioning. There was evidence in the clinical records reviewed that the hospice aide was providing care and services to patients as early as 3/30/2023. The Clinical Director was interviewed on 5/24/2023 and confirmed the hospice aide skills competency did not include all required tasks prior to the hospice aide performing the tasks independently. Agency policy, “Hospice Aide Services and Training Program,” stated in part, “All hospice aides employed by hospice will satisfactorily complete a hospice aide training program and/or competency evaluation program prior to performing patient care. Training must include a record that distinguishes between skills taught at a patient’s bedside with supervision and those taught in a laboratory and indicators of which skills each aide was judged to be competent. Supervised practical training is defined as training in a laboratory or other setting in which the hospice aide demonstrates knowledge while performing tasks on an individual under the direct supervision of an RN. The hospice aide will not perform a particular task without direct supervision by a RN and until training is completed and a satisfactory evaluation is achieved.” Record 6 (Hospice Aide): hire date 3/1/2023. A skills competency was completed by the RN on 3/29/2023 that included: ambulate with gait belt, sit to stand transfers, stand pivot transfers and sliding board transfers. There was no documented evidence that an RN observed competency of skills in the following areas: Reading and recording temperature, pulse, and respiration, bed bath, sponge bath, shower bath, hair shampoo, nail and skin care, oral hygiene, toileting and elimination, normal range of motion and positioning. There was evidence in the clinical records reviewed that the hospice aide was providing these cares to patients. The Clinical Director was interviewed on 5/24/2023 and agreed, there was no documented evidence that the hospice aide skills competency was completed prior to the hospice aide performing the tasks independently.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 8 (25%) clinical records reviewed with hospice aide services ordered revealed the hospice did not ensure that the hospice aide provided services in accordance with the plan of care. Record 2: The patient’s date of hospice election was 5/3/2023. The hospice aide care plan dated 5/3/2023 assigned instructions for the aide to complete the following tasks every visit: bed bath, shampoo, shaving, change linens. The hospice aide visit documentation on 5/16/2023 revealed shampoo, shaving, bed linens not completed not required this visit. The hospice aide visit documentation on 5/19/2023 revealed bed bath, shampoo not completed not required this visit. Record 7: The patient’s date of hospice election was 3/30/2023. The hospice aide care plan dated 4/18/2023 assigned instructions for the aide to complete the following tasks every visit: shampoo, date of last BM. The hospice aide visit documentation on 4/21/2023 revealed shampoo, date of last BM not completed not required this visit. The Clinical Director was interviewed on 5/24/2023 and agreed, the hospice aide did not follow the plan of care as ordered. Record 2: The patient’s date of election was 5/3/2023. The hospice aide care plan dated 5/3/2023 assigned instructions for the aide to complete every visit: bed bath, shampoo, shaving, change linens. The hospice aide visit documentation on 5/16/2023 revealed shampoo, shaving, bed linens not completed not required this visit. The hospice aide visit documentation on 5/19/2023 revealed bed bath, shampoo not completed not required this visit. Record 7: The patient’s date of election was 3/30/2023. The hospice aide care plan dated 4/18/2023 assigned instructions for the aide to complete every visit: shampoo, date of last BM. The hospice aide visit documentation on 4/21/2023 revealed shampoo, date of last BM not completed not required this visit. The Clinical Director was interviewed on 5/24/2023 and agreed, the hospice aide did not follow the plan of care as ordered.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. 3 of 8 (38%) clinical records reviewed of patients with a hospice aide services ordered, revealed the agency did not ensure hospice aides reported changes in the patient's medical, nursing, and social needs as the changes related to the plan of care, to a registered nurse. Record 1: The patient’s date of hospice election was 5/5/2023. The hospice aide care plan dated 5/5/2023 assigned instructions for the aide to complete the following task every visit: shaving. The hospice aide visit documentation on 5/8/2023 revealed shaving not completed patient refused. There was no documented evidence that the registered nurse was notified. Record 3: The patient’s date of hospice election was 5/17/2023. The hospice aide care plan dated 5/17/2023 assigned instructions for the aide to complete the following task every visit: shaving. The hospice aide visit documentation on 5/19/2023 revealed shaving not completed patient refused. There was no documented evidence that the registered nurse was notified. Record 7: The patient’s date of hospice election was 3/30/2023. The hospice aide care plan dated 3/30/2023 assigned instructions for the aide to complete the following tasks every visit: shower, shampoo, temperature, B/P, respirations, pulse. The hospice aide visit documentation on 3/30/2023 revealed shower and shampoo not completed patient refused. The hospice aide visit documentation on 3/31/2023 revealed temperature, B/P, respirations, pulse not completed patient refused. There was no documented evidence in the clinical record that the registered nurse was notified. The Clinical Director was interviewed on 5/24/2023 and stated, the hospice aide is expected to notify the registered nurse if the patient refused care and the aide assignment could not be followed. Additionally, during an interview on 5/24/2023, the Clinical Director agreed, there was no documented evidence that the hospice aide notified the registered nurse with the changes. Agency policy, “Hospice Aide Services,” stated in part, “Hospice Aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities.” Record 1: The patient’s date of election was 5/5/2023. The hospice aide care plan dated 5/5/2023 assigned instructions for the aide to complete every visit: shaving. The hospice aide visit documentation on 5/8/2023 revealed shaving not completed patient refused. There was no documented evidence that the registered nurse was notified. Record 3: The patient’s date of election was 5/17/2023. The hospice aide care plan dated 5/17/2023 assigned instructions for the aide to complete every visit: shaving. The hospice aide visit documentation on 5/19/2023 revealed shaving not completed patient refused. There was no documented evidence that the registered nurse was notified. Record 7: The patient’s date of election was 3/30/2023. The hospice aide care plan dated 3/30/2023 assigned instructions for the aide to complete every visit: shower, shampoo, temperature, B/P, respirations, pulse. The hospice aide visit documentation on 3/30/2023 revealed shower and shampoo not completed patient refused. The hospice aide visit documentation on 3/31/2023 revealed temperature, B/P, respirations, pulse not completed patient refused. There was no documented evidence that the registered nurse was notified. The Clinical Director was interviewed on 5/24/2023 and stated, the hospice aide is expected to notify the registered nurse if the patient refused care and the aide assignment could not be followed. Additionally, during an interview on 5/24/2023, the Clinical Director agreed, there was no documented evidence that the hospice aide notified the registered nurse with the changes.

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; and documented in the patient record, including time spent. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by clinical record review, personnel record review and interview with the Clinical Director, Volunteer Coordinator and Executive Director which revealed the following issues with the volunteer program: Failed to provide volunteer services in day-to-day administrative and/or direct care roles [HCDT.21.I/L644]; and Failed to ensure the hospice was primarily engaged in providing volunteer services in a manner that is consistent with accepted standards of practice [ HCDT.1.I/L652]. The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to ensure volunteer services are available to support hospice care.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. 8 of 8 (100%) clinical records reviewed revealed the hospice did not ensure volunteer services were offered or provided to patient’s/families. Agency Policy, “Volunteer Services,” stated in part, “...ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs.” Record 1: The patient’s date of hospice election was 5/5/2023. The plans of care, Interdisciplinary Group Meeting documentation, and comprehensive assessments completed by the registered nurse and social worker were reviewed. There was no documented evidence in the clinical record that volunteer services were offered or provided to the patient. Record 2: The patient’s date of hospice election was 5/3/2023. The plans of care, Interdisciplinary Group Meeting documentation, and comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patient. Record 3: The patient’s date of election was 5/17/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments completed by the registered nurse and social worker were reviewed. There was no documented evidence in the clinical record that volunteer services were offered or provided to the patient. Record 4: The patient’s date of election was 5/15/2023. The plans of care, Interdisciplinary Group meeting documentation, and comprehensive assessments completed by the registered nurse and social worker were reviewed. There was no documented evidence in the clinical record that volunteer services were offered or provided to the patient. Record 5: The patient’s date of hospice election was 5/4/2023. The plans of care, Interdisciplinary Group Meeting documentation, and comprehensive assessments completed by the registered nurse and social worker were reviewed. There was no documented evidence in the clinical record that volunteer services were offered or provided to the patient. Record 6: The patient’s date of hospice election was 4/25/2023. The plans of care, Interdisciplinary Group Meeting documentation, and comprehensive assessments completed by the registered nurse and social worker were reviewed. There was no documented evidence in the clinical record that volunteer services were offered or provided to the patient. Record 7: The patient’s date of hospice election was 3/30/2023. The plans of care, Interdisciplinary Group Meeting documentation, and comprehensive assessments completed by the registered nurse and social worker were reviewed. There was no documented evidence in the clinical record that volunteer services were offered or provided to the patient. Record 8: The patient’s date of hospice election was 4/7/2023. The plans of care, Interdisciplinary Group Meeting documentation and comprehensive assessments completed by the registered nurse and social worker were reviewed. There was no documented evidence in the clinical record that volunteer services were offered or provided to the patients. The Clinical Director, who is also the admissions nurse, was interviewed on 5/22/2023 and stated, “I don’t offer volunteers, I tell them what they can do and let them know the social worker will follow up.” The Volunteer Coordinator, who is also the social worker, was interviewed on 5/22/2023 and stated, “I haven’t offered a volunteer to anyone, since we don’t have a volunteer in place. I let them know that once we have a volunteer in place, I will update them to see if they want one.” The Executive Director was interviewed on 5/22/2023 and stated, we could have the volunteer coordinator do the volunteer visits if someone needs it.” Agency policy, “Volunteer Services,” stated in part, “ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs.” Record 1: The patient’s date of election was 5/5/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patients. Record 2: The patient’s date of election was 5/3/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patients. Record 3: The patient’s date of election was 5/17/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patients. Record 4: The patient’s date of election was 5/15/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patients. Record 5: The patient’s date of election was 5/4/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patients. Record 6: The patient’s date of election was 4/25/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patients. Record 7: The patient’s date of election was 3/30/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patients. Record 8: The patient’s date of election was 4/7/2023. The plans of care, Interdisciplinary Group meetings, comprehensive assessments by the registered nurse and social worker were reviewed. There was no documented evidence that volunteer services were offered or provided to the patients. The Clinical Director, who is also the admissions nurse, was interviewed on 5/22/2023 and stated, “I don’t offer volunteers, I tell them what they can do and let them know the social worker will follow up.” The Volunteer Coordinator, who is also the social worker, was interviewed on 5/22/2023 and stated, “I haven’t offered a volunteer to anyone, since we don’t have a volunteer in place. I let them know that once we have a volunteer in place, I will update them to see if they want one.” The Executive Director was interviewed on 5/22/2023 and stated, we could have the volunteer coordinator do the volunteer visits if someone needs it.”

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: hospice aide, volunteer and homemaker services. This standard was not met as evidenced by personnel record review and interview. A review of personnel files revealed there was no evidence that the hospice was engaged in providing volunteer services. There were no volunteer personnel files that included evidence of volunteer training, completion of volunteer competencies, or signed volunteer job descriptions. There is no evidence that volunteer services have been provided as required.

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 interview and personnel record review. 3 of 3 (100%) personnel records reviewed for staff that provided direct care, revealed the hospice did not assess the skills and competencies of all individuals providing care. Personnel Record 2 (Clinical Director/Registered Nurse Case Manager): Hire date 4/13/2023. There was no documented evidence a competency evaluation was completed. Personnel Record 4 (Social Worker): Hire date 4/6/20233. There was no documented evidence a competency evaluation was completed. Personnel Record 5 (Spiritual Care Counselor): Hire date 2/3/2023. There was no documented evidence a competency evaluation was completed. The policy on competency assessments was requested on day 1, 2 and 3. The Executive Director was interviewed on 5/23/2023 and stated, we are looking for that policy.” During an interview on 5/23/2023, the Executive Director revealed a printout of initial job specific competencies for the registered nurse, social worker, and spiritual counselor that were not filled in and stated, “these are the ones we should be using but have not yet.” There was no further documentation provided by the agency prior to the survey exit on 5/24/2023. Record 2 (Clinical Director/Registered Nurse Case Manager): hire date 4/13/2023. There was no documented evidence a competency evaluation was completed. Record 4 (Social Worker): hire date 4/6/20233. There was no documented evidence a competency evaluation was completed. Record 5 (Spiritual Care Counselor): hire date 2/3/2023. There was no documented evidence a competency evaluation was completed. The policy on competency assessments was requested on day 1, 2 and 3. The Executive Director was interviewed on 5/23/2023 and stated, we are looking for that policy.” During an interview on 5/23/2023, the Executive Director revealed a printout of initial job specific competencies for the registered nurse, social worker, and spiritual counselor that were not filled in and stated, “these are the ones we should be using but have not yet.” There was no further documentation provided by the agency prior to the survey exit on 5/24/2023.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 clinical record review and interview. 8 of 8 (100%) clinical records reviewed revealed the hospice did not ensure the election statement included notification of the beneficiary’s (or representative’s) right to request an election statement addendum. Clinical Record 1: The Medicare Benefit Election signed by the patient’s representative on 5/5/2023 did not include documented evidence that the beneficiary (or representative) was notified of the right to request an election statement addendum that included a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Clinical Record 2: The Medicare Benefit Election signed by the patient on 5/3/2023 did not include documented evidence that the beneficiary (or representative) was notified of the right to request an election statement addendum that included a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 3: The Medicare Benefit Election signed by the patient’s representative on 5/16/2023 did not include documented evidence that the beneficiary (or representative) was notified of the right to request an election statement addendum that included a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 4: The Medicare Benefit Election signed by the patient on 5/15/2023 did not include documented evidence that the beneficiary (or representative) was notified of the right to request an election statement addendum that included a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 5: The Medicare Benefit Election signed by the patient’s representative on 5/4/2023 did not include documented evidence that the beneficiary (or representative) was notified of the right to request an election statement addendum that included a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 6: The Medicare Benefit Election signed by the patient’s representative on 4/25/2023 did not include documented evidence that the beneficiary (or representative) was notified of the right to request an election statement addendum that included a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 7: The Medicare Benefit Election signed by the patient’s representative on 3/30/2023 did not include documented evidence that the beneficiary (or representative) was notified of the right to request an election statement addendum that included a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 8: The Medicare Benefit Election signed by the patient’s representative on 4/7/2023 did not include documented evidence that the beneficiary (or representative’s) was notified of the right to request an election statement addendum that included a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. The Executive Director was interviewed on 5/24/2023 and agreed, there was no documented evidence the hospice's election statement included notification of the patients' (or representatives') right to request the election statement addendum. Additionally, during an interview on 5/24/2023, the Executive Director stated, “we realize what is missing and are in the process of updating the forms.” Record 1: The Medicare Benefit Election signed by the patient’s representative on 5/5/2023 did not include documented evidence that the beneficiary’s (or representative’s) was notified of the right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 2: The Medicare Benefit Election signed by the patient on 5/3/2023 did not include documented evidence that the beneficiary’s (or representative’s) was notified of the right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 3: The Medicare Benefit Election signed by the patient’s representative on 5/16/2023 did not include documented evidence that the beneficiary’s (or representative’s) was notified of the right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 4: The Medicare Benefit Election signed by the patient on 5/15/2023 did not include documented evidence that the beneficiary’s (or representative’s) was notified of the right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 5: The Medicare Benefit Election signed by the patient’s representative on 5/4/2023 did not include documented evidence that the beneficiary’s (or representative’s) was notified of the right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 6: The Medicare Benefit Election signed by the patient’s representative on 4/25/2023 did not include documented evidence that the beneficiary’s (or representative’s) was notified of the right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 7: The Medicare Benefit Election signed by the patient’s representative on 3/30/2023 did not include documented evidence that the beneficiary’s (or representative’s) was notified of the right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. Record 8: The Medicare Benefit Election signed by the patient’s representative on 4/7/2023 did not include documented evidence that the beneficiary’s (or representative’s) was notified of the right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions. The Executive Director was interviewed on 5/24/2023 and agreed, there was no documented evidence the hospice's election statement included notification of the patient (or representative’s) right to request the election statement addendum. Additionally, during an interview on 5/24/2023, the Executive Director stated, “we realize what is missing and are in the process of updating the forms.”