Every finding on record at Luminous Hospice Care Inc

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. AND The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. AND The hospice maintains documentation that each hospice aide has met the requirements. The competency evaluation addresses each of the following subject areas from item 2, above; they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; Hair shampoo (sink, tub, and bed); Nail and skin care; Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. This standard was not met as evidenced by personnel record review and interview. In 1 of 1 (100%) hospice aide personnel records reviewed, the agency did not ensure documentation of the aide skills competency testing was assessed on an actual patient or a pseudo patient. Personnel Record 5: Certified Nurse Aide date of hire 09/10/2023. The initial aide skills competency dated 09/10/2023 included documentation that all skills were signed off as completed. The section to document which patient/medical record number the skills were completed on was left blank and the form did not provide documentation that the skills were completed in a lab setting (pseudo patient). During an interview on 11/17/2023, the Administrator/Director of Nursing confirmed the finding.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan: Is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served; Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of: a) Power failures; b) Natural or man-made disasters; c) Emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk; and d) Other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by document review and interview. Review of the emergency preparedness binder revealed no documented evidence the comprehensive emergency program was based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. The hospice did not ensure an all-hazards vulnerability analysis was completed. The emergency preparedness policy and procedure include a procedure to complete a hazard vulnerability analysis. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse stated, "I do not have the hazard analysis." Review of the emergency preparedness binder revealed no evidence the comprehensive emergency program that used an all hazards approach. The hospice did not ensure an all hazards vulnerability analysis was completed. The emergency preparedness policy and procedure include a procedure to complete a hazard vulnerability analysis. During interview 10/27/23, the Executive Director/Clinical Director/RN stated, "I do not have the hazard analysis".

It is required that the written Patient Bill of Rights includes the right to voice grievances to the hospice, CHAP, or a state entity without fear of discrimination or reprisal and voice grievances regarding treatment or care that is—or fails to be—provided. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 3 (100%) clinical records reviewed, the hospice did not ensure the Patient Bill of Rights included information to voice grievances when it did not include contact information for the hospice, CHAP, or the state agency. The admission folder provided to patients at the start of care included a paper titled “Patient Care Information.” The paper stated, if we are not meeting your expectations of our service, please feel free to contact us first or one of the following: (HOSPICE) and a phone number and included the name and phone number of another accrediting organization, not CHAP. The Patient Care Information paper did not include the name of the hospice caring for the patient and did not include the CHAP name and phone number for reporting grievances. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed no documented evidence that the patient was informed of the process to report a grievance. There was no documented evidence that contact information including name and phone number for the hospice agency, CHAP or the state entity was provided to the patient. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. Clinical record review revealed no documented evidence that the patient was informed of the process to report a grievance. There was no documented evidence that contact information including name and phone number for the hospice agency, CHAP or the state entity was provided to the patient. Clinical Record 3: The patient elected the hospice benefit on 10/25/2023. Clinical record review revealed no documented evidence that the patient was informed of the process to report a grievance. There was no documented evidence that contact information including name and phone number for the hospice agency, CHAP or the state entity was provided to the patient. During an interview on 10/26/2023, the Executive Director/Clinical Director/Registered Nurse stated, "We have the Patient Care Information paper we give the patients on admission, but we do not have a copy for the clinical record. What we give the patient does not include the name of our hospice if the patient wants to report a complaint. The paper we give the patient does not include the grievance process to notify CHAP, and it only includes the name of another accrediting organization, not CHAP. We got the "Patient Care Information" paper from someone in (another state).” During interview 10/26/23, the Executive Director/Clinical Director/RN stated, "We have the "Patient Care Information" paper we give the patients on admission but we do not have a copy for the clinical record", "What we give the patient does not include the name of our hospice if the patient wants to report a complaint", "The paper we give the patient does not include the grievance process to notify CHAP, and it only includes the name of another accreditation agency, not CHAP", and "We got the "Patient Care Information" paper from someone in (another state)".

It is required that the written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 3 (100%) clinical records reviewed, the hospice did not ensure the Patient Bill of Rights form included the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source and the misappropriation of patient property. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. The patient/representative signed a statement on admission dated 10/10/2023 confirming the patient received a copy of the "Patient Rights and Responsibilities" form. The “Patient Rights and Responsibilities” form did not include the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source and the misappropriation of patient property. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. The patient/representative signed a statement on admission dated 09/19/2023 confirming the patient received a copy of the "Patient Rights and Responsibilities" form. The “Patient Rights and Responsibilities” form did not include the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source and the misappropriation of patient property. Clinical Record 3: The patient elected the hospice benefit on 10/25/2023. The patient/representative signed a statement on admission dated 10/25/2023 confirming the patient received a copy of the "Patient Rights and Responsibilities" form. The “Patient Rights and Responsibilities” form did not include the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source and the misappropriation of patient property. During an interview on 10/26/2023, the Executive Director/Clinical Director/Registered Nurse stated, "Yes, I see that part is missing from the Patient Rights form. We are using this form that someone gave us." During interview 10/26/23, the Executive Director/Clinical Director/RN stated, "Yes, I see that part is missing off the Patient Rights form", and "We are using this form that someone gave us".

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 CITATION CITED AT IMMEDIATE JEOPARDY. This condition of participation which is being cited at Immediate Jeopardy was not met as evidenced by clinical record review and interview with the Executive Director /Clinical Director /Registered Nurse which revealed issues related to the completion and documentation of the patients' initial and comprehensive assessment in the following areas: Failure to ensure the Registered Nurse completed an initial assessment within 48 hours of the patient's election of hospice benefit [HCPC.8.I/L522]; Failure to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of benefit [HCPC.9.I/L523]; Failure to ensure an accurate medication profile is developed as part of the comprehensive assessment [HCPC.15.I/L530]; Failure to ensure the initial bereavement assessment is completed as part of the comprehensive assessment [HCPC.13.I/L531]; and Failure to ensure the updated comprehensive assessment is completed by the hospice Interdisciplinary Group no less frequently than every 15 days [HCPC.17.I/L533]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.54: Initial and Comprehensive Assessment of Patient. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency. During interview 10/27/23, the Executive Director/Clinical Director stated, "The initial assessments are not documented in the clinical record", "I have my RN initial assessments in my notebook but I do not have notes for the initial nursing assessment on (Record 1) which I did on 10/10/23", and "The consultant gave me paper forms to use for the initial assessments, but I did not use them".

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s 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 and interview. In 2 of 3 (67%) clinical records reviewed, the hospice did not ensure the hospice Registered Nurse (RN) completed an initial assessment within 48 hours of the patient’s election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed no documented evidence that the hospice RN completed an initial nursing assessment within 48 hours of the patient’s election of hospice care, as of the date of record review on 10/27/2023. During an interview on 10/27/2023, the Executive Director /Clinical Director /RN (staff 1) confirmed the initial nursing assessment was not in the clinical record and stated, "I have a notebook where I have been keeping notes of the assessments and visits that I make. I do not know why I do not see an entry in my notebook for the initial visit I made on 10/10/2023." Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. Clinical record review revealed no documented evidence that the hospice RN completed an initial nursing assessment within 48 hours of the patient’s election of hospice care, as of the date of record review on 10/27/2023. During an interview on 10/27/2023, the Executive Director /Clinical Director /RN (staff 1) confirmed the initial nursing assessment was not in the clinical record and stated, "I have a notebook where I have been keeping notes of the assessments and visits that I make." Review of the RN's personal notebook identified a partial nursing assessment dated 09/19/2023. During an interview on 10/27/2023, the Executive Director /Clinical Director /RN explained the agency has purchased an electronic medical record (EMR), but staff have not been trained yet on how to enter documentation in the system. The Executive Director /Clinical Director /RN stated, "Staff do not enter their assessments or visit notes into the clinical record, they just keep paper forms on visits they have done, and they will add their documentation into the clinical record once they get trained on the new EMR which we just implemented in the past week."

It is required that the hospice Interdisciplinary Group (IDG), 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 and interview. In 2 of 2 (100%) clinical records of patients on service greater than 5 days, the hospice did not ensure the comprehensive assessment was completed no later than five calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed no documented evidence that the initial comprehensive assessment was completed, as of the date of record review on 10/27/2023. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse (RN) (staff 1) stated, "Staff do not enter their assessments or visit notes into the clinical record, they just keep paper forms on visits they have done, and they will add their documentation into the clinical record once they get trained on the new electronic medical record (EMR) which we just implemented in the past week. The consultant gave me paper formats to use but I did not use them.” Review of the RN's personal notebook used for documenting visit notes revealed no documented notes or entries that would confirm a nursing visit occurred on 10/10/2023. During an interview on 10/27/2023, the Spiritual Counselor (staff 4) stated “I have not seen or assessed this patient.” During an interview on 10/27/2023, the Social Worker stated, “I saw the patient and completed the initial psychosocial and bereavement assessment on a paper form but have not submitted the assessment documentation to the hospice.” The patient’s clinical record contained no documented evidence that the IDG in collaboration with the patient’s attending physician had completed a comprehensive assessment of the patient. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. Clinical record review revealed no documented evidence that the initial comprehensive assessment was completed, as of the date of record review on 10/27/2023. Review of the RN's (staff 1) personal notebook, that is not part of the clinical record, used for documenting visit notes revealed a partial nursing assessment dated 09/19/2023. During an interview on 10/17/2023, the Spiritual Counselor stated, "I have seen this patient twice, once for the initial assessment and then a follow up visit, but I have not submitted the visit documentation to the hospice." During an interview on 10/27/2023, the Social Worker stated, “I saw the patient and completed the initial psychosocial and bereavement assessment on a paper form but have not submitted the assessment documentation to the hospice.” The patient’s clinical record contained no documented evidence that the IDG, in collaboration with the patient’s attending physician had completed a comprehensive assessment for the patient.

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 following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy associated with laboratory monitoring. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients on service greater than 5 days, the hospice did not ensure a complete review of the patient’s medications was completed as part of the comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed no evidence of a verbal order or a signed physician order for the medications listed on the medication profile. During telephone interview on 10/27/2023, the patient's spouse stated they were still waiting for the patient’s blood pressure medication Lisinopril to be delivered and that the nurse and doctor told them on 10/10/2023 the patient needed to take the Lisinopril. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse (RN) stated, “I forgot to get the order and have the medications delivered. The verbal order was obtained today 10/27/2023 for Lisinopril and Ativan to be delivered today by 5:00 pm. During the interview on 10/27/2023 at 5:00 pm, the wife stated the medications were delivered to the patient. The clinical record contained no documented evidence that a review of the patient’s current medications had been completed as part of the comprehensive assessment.

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 and interview. In 2 of 2 (100%) clinical records reviewed of patients on service greater than 5 days, the hospice did not ensure the initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed for the patient. During an interview on 10/27/2023, the hospice Social Worker stated she had seen the patient and completed the initial bereavement assessment on a paper form but had not submitted the assessment documentation to the hospice. Clinical Record 2: The patient elected the hospice benefit on 09/19/23. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed for the patient. During an interview on 10/27/2023, the hospice Social Worker stated she had seen the patient and completed the initial bereavement assessment on a paper form but had not submitted the assessment documentation to the hospice. During an interview on 10/26/2023, the Executive Director /Clinical Director /Registered Nurse stated, “We just got a new electronic medical record (EMR) system in the past week, and we (staff) have been keeping notes since we admitted patients in the middle of September and plan to put the note entries into the EMR once we are trained. The consultant has been training me on the new (EMR) and the rest of the staff will receive training November 1st." During interview 10/6/23, the Executive Director/Clinical Director/RN stated staff have not received training on the new computer system and that they are holding onto their notes until they can be entered into the new electronic medical record (EMR).

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed: as frequently as the condition of the patient requires but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients on service greater than 15 days, the hospice did not ensure the Interdisciplinary Group (IDG) update of the comprehensive assessment no less frequently than every 15 days. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. The clinical record contained no documented evidence that the IDG had updated the patient’s comprehensive assessment at least every 15 days. As of the date of record review on 10/27/2023, the clinical record contained no evidence that an IDG meeting had been completed and no documented updates to the comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. The clinical record contained no documented evidence that the IDG had updated the patient’s comprehensive assessment at least every 15 days. As of the date of record review on 10/27/2023, the clinical record contained no evidence that an IDG meeting had been completed and no documented updates to the comprehensive assessment. During an interview on 10/26/2023, the Registered Nurse (RN) /Executive Director /Clinical Director stated, "The IDG have been meeting every 2 weeks on a Wednesday by Zoom but we have not been documenting it yet." The RN /Executive Director /Clinical Director later stated on 10/27/2023, "I meant the IDG have been meeting in person at the office every 2 weeks." During an interview on 10/27/2023 the Medical Director stated, "I stop by the hospice in person frequently sometimes daily to talk to the RN about the patients, but the social worker and spiritual counselor are not present or on Zoom." During an interview on 10/27/23, the Social Worker and Spiritual Counselor both stated, "I have not attended a IDG at this hospice either in person or by Zoom yet; since we have not started IDG meetings yet." During interview 10/26/23, the RN/Executive Director/Clinical Director confirmed missing IDG meetings and reassessments in the clinical record and stated, "The IDG have been meeting every 2 weeks on a Wednesday by Zoom but we have not been documenting it yet". Later on 10/27/23, the RN/Executive Director/Clinical Director stated, "I meant the IDG have been meeting here in person in the office every 2 weeks". During interview 10/27/23, the Medical Director stated, "I stop by the hospice in person frequently sometimes daily to talk to the RN about the patients and the social worker and spiritual counselor are not present or on Zoom". During interview 10/27/23, both the Social Worker and Spiritual Counselor stated, "I have not attended a IDG at this hospice either in person or by Zoom yet since we have not started IDG meetings yet".

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AT IMMEDIATE JEOPARDY. This condition of participation, which was also cited at Immediate Jeopardy, was not met as evidenced by review of clinical records and interviews with the Executive Director /Clinical Director /Registered Nurse which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure to ensure the Registered Nurse provided coordination of care, continuous assessment of each patient's needs and implementation of the Interdisciplinary Group (IDG) plan of care [HCPC.19.I/L540]; Failure to ensure the IDG in collaboration with the attending physician, the patient and caregiver development of an individualized plan of care outlining hospice care and services to be provided to the patient and family [HCPC.19.I/L543]; Failure to ensure the individualized plan of care reflected patient and family goals and identified planned interventions, based problems identified in the initial and updated comprehensive assessment [HCPC.21.I/L545]; Failure to ensure the IDG reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days [HCPC.22.I/L552]; and Failure to ensure policies and procedures ensure that the Interdisciplinary Group maintains responsibility for directing, coordinating, and supervising the care and services provided [HCPC.23.E/L554]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary Group, Care Planning, and Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency. director "staff will be trained on how to use the EMR November 1st".

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs and ensure the implementation of the interdisciplinary (IDG) plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed, the hospice did not ensure the Registered Nurse provided coordination of care, continuous assessment of each patient's needs, and implementation of the IDG plan of care. Clinical Record 1: Patient elected the hospice benefit on 10/10/2023. Clinical record review revealed the IDG plan of care had not been established for the patient. The clinical record contained no documented evidence of physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. The clinical record contained no documented evidence of patient or family assessments, discipline visit notes (expect for the hospice aide), and IDG coordination of care. The medication profile listed Ativan as needed with a start date of 10/10/2023. The clinical record did not include a physician order for Ativan. During telephone interview on 10/27/2023, the patient's spouse stated they were still waiting for the patient’s blood pressure medication Lisinopril to be delivered and that the nurse and doctor told them on 10/10/2023 the patient needed to take the Lisinopril. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse (RN) stated, “I forgot to get the order and have the medications delivered. The verbal order was obtained today (10/27/2023) for Lisinopril and Ativan to be delivered today by 5:00 pm." During the interview on 10/27/2023 at 5:00 pm, the wife stated the medications were delivered to the patient. The RN member of the IDG did not ensure documentation and coordination of care was delivered to meet the hospice patient’s needs. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. Clinical record review revealed the IDG plan of care had not been established for the patient. The clinical record contained no documented evidence of physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. The clinical record contained no documented evidence of patient or family assessments, discipline visit notes (expect for the hospice aide), and IDG coordination of care. During an interview on 10/27/2023, the Executive Director /Clinical Director /RN stated she had provided visits to the patient and had a paper notebook where she was keeping documentation of the nursing visits until she was trained and could enter them into the new electronic medical record (EMR). Review of the RN's paper notebook revealed a nursing visit dated 09/22/2023 which did not include an assessment of the cardiovascular and respiratory system and weekly nursing visit entries which were incomplete with documentation that stated, "patient stated" with no additional documentation entered. The Executive Director /Clinical Director /RN stated she saw the patient on 10/25/2023, the paper notebook and/or the clinical record did not include documentation for the 10/25/2023 nursing visit. The RN member of the IDG did not ensure documentation and coordination of care was delivered to meet the hospice patient’s needs. Clinical Record 3: Patient elected the hospice benefit on 10/25/2023. Clinical record review revealed the IDG plan of care had not been established for the patient. The clinical record contained no documented evidence of physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. The clinical record contained no documented evidence of patient or family assessments, discipline visit notes (expect for the hospice aide), and IDG coordination of care. During a telephone interview 10/27/2023, the patient stated, “I get short of breath when I get up and move around. I requested oxygen on Wednesday (10/25/2023), and I am still waiting for the oxygen to be delivered." During an interview on 10/27/23, the Executive Director /Clinical Director /RN stated, "I forgot." The DME provider was then scheduled to deliver oxygen by 3:00 pm on 10/27/2023. During a telephone interview at 3:00 pm the patient stated, "Yes, the oxygen was delivered." The RN member of the IDG did not ensure documentation and coordination of care was delivered to meet the hospice patient’s needs. During an interview on 10/27/2023, the Executive Director /Clinical Director /RN stated, "We have not done a plan of care yet. We just got a new electronic medical record (EMR) system in the past week, and we have been keeping notes since we admitted patients in the middle of September and plan to put the note entries into the EMR once we are trained. The consultant has been training me on the new (EMR) and the rest of the staff will receive training November 1st.” During interview 10/27/23, the RN/Executive Director/Clinical Director stated, "We have not done a plan of care yet", "We just got a new computer system (EMR) in the past week and we have been keeping notes since we admitted patients the middle of September and plan to put the note entries into the (EMR) once we are trained", "The consultant has been training me on the new (EMR) and the rest of the staff will receive training November 1st".

It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by, the hospice IDG (interdisciplinary group) in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (67%) clinical records reviewed, the hospice did not ensure the IDG in collaboration with the attending physician, the patient and caregiver development of an individualized plan of care outlining hospice care and services to be provided to the patient and family. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed the IDG plan of care had not been established for the patient. The clinical record contained no documented evidence of physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. Clinical record review revealed the IDG plan of care had not been established for the patient. The clinical record contained no documented evidence of physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. Clinical Record 3: The patient elected the hospice benefit on 10/25/2023. Clinical record review revealed the IDG plan of care had not been established for the patient. The clinical record contained no documented evidence of physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. During an interview on 10/27/2023, the Registered Nurse (RN) /Executive Director /Clinical Director stated, "We have not done a plan of care yet, either in the EMR (Electronic Medical Record) or on paper. We just got a new EMR system in the past week and we still need training on how to do the plan of care.” The RN /Executive Director /Clinical Director confirmed the hospice started admitting patients the middle of September and the patient’s plans of care were no developed as of the date of record review on 10/27/2023. During interview 10/27/23, the RN/Executive Director/Clinical Director stated, "I did not enter the orders for the staff visits and medications into the new computer program yet since I have not had training, but I entered the orders into the computer system today for (Clinical Record #3) after training from the consultant". The RN/Executive Director/Clinical Director stated, "The Hospice aide has experience with (EMR) and does document his aide notes into the EMR". Additionally, the RN/Executive Director/Clinical Director stated, "Yes, my notebook includes that the medical director made a visit to the patient on 10/12/23 but it is not documented in the clinical record". During phone interview 10/27/23, the social worker stated, "I have completed the initial psychosocial and bereavement assessments for (Clinical record # 1 and 2) and (Clinical record #3) is new and scheduled on 10/30/23 for the initial assessments", "I am visiting (Record 1 and 2) on a monthly basis", and "I am documenting on paper format forms and have not brought the notes and assessments into the hospice yet but will send them to the office today". No social worker assessment or visit notes were submitted to the hospice by end of site visit. During phone interview 10/27/23, the spiritual counselor stated, "I have only visited (Clinical Record #2) two times, the initial spiritual assessment and a follow up visit", "I am documenting on paper and have not brought the notes and assessments into the hospice yet", and "I am on my way out of town and cannot send the assessment and visit note to the hospice today".

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 3 of 3 (100%) clinical records reviewed, the hospice did not ensure the individualized plan of care reflected patient and family goals and identified planned interventions, based problems identified in the initial and updated comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed no documented evidence that an individualized plan of care was developed for the patient. The clinical record did not include a plan of care that reflected patient and family goals and planned interventions based on the initial and updated comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. Clinical record review revealed no documented evidence that an individualized plan of care was developed for the patient. The clinical record did not include a plan of care that reflected patient and family goals and planned interventions based on the initial and updated comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 10/25/2023. Clinical record review revealed no documented evidence that an individualized plan of care was developed for the patient. The clinical record did not include a plan of care that reflected patient and family goals and planned interventions based on the initial and updated comprehensive assessment. During an interview on 10/27/2023, the Registered Nurse (RN) /Executive Director /Clinical Director stated, "We have not done a plan of care yet, either in the EMR (Electronic Medical Record) or on paper. We just got a new EMR system in the past week and we still need training on how to do the plan of care.” The RN /Executive Director /Clinical Director confirmed the hospice started admitting patients the middle of September and the patient’s plans of care were no developed as of the date of record review on 10/27/2023. During interview 10/27/23, the RN/Executive Director/Clinical Director stated, "We have not done a plan of care yet, either in the (EMR) or on paper", "We just got a new computer system (EMR) in the past week" and "We still need training on how to do the plan of care". Additionally, the RN/Executive Director/Clinical Director stated, "The clinical record is missing verbal orders for medications on (Record 1 and 2)", "I added a medication profile to all 3 clinical records but did not know how to enter in the verbal orders for medications and treatments for (Record 1 and 2)", and "I just learned today how to enter the verbal orders into the (EMR) on the new patient admitted 10/25/23 (Record 3)".

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records of patients on service greater than 15 days, the hospice did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed no documented evidence that the IDG had reviewed, revised, or updated the care plan every 15 days, as of the date of record review on 10/27/2023. The clinical record did not include an individualized care plan for the patient and no documentation of IDG review of a care plan. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. Clinical record review revealed no documented evidence that the IDG had reviewed, revised, or updated the care plan every 15 days, as of the date of record review on 10/27/2023. The clinical record did not include an individualized care plan for the patient and no documentation of IDG review of a care plan. During interview 10/26/23, the Registered Nurse (RN) /Executive Director /Clinical Director confirmed the clinical records were missing documentation of IDG meetings with review of the patient’s care plans. The RN /Executive Director /Clinical Director stated, "The IDG have been meeting every 2 weeks on a Wednesday by Zoom but we have not been documenting it yet." Later, during an interview on 10/27/2023, the RN /Executive Director /Clinical Director stated, "I meant the IDG have been meeting here in person in the office every 2 weeks." During an interview on 10/27/2023, the Medical Director stated, "I stop by the hospice frequently sometimes daily to talk to the RN about the patients and the social worker and spiritual counselor are not present or on Zoom." During an interview on 10/27/2023, the Social Worker and the Spiritual Counselor both confirmed they have not attended an IDG meeting at this hospice yet either in person or by Zoom and stated we have not started IDG meetings yet. During interview 10/26/23, the RN/Executive Director/Clinical Director confirmed the missing IDG/IDT meetings, missing IDG review and revisions of the plan of care, and missing comprehensive reassessment updates in the clinical record or paper format and stated, "The IDG have been meeting every 2 weeks on a Wednesday by Zoom but we have not been documenting it yet". Later on 10/27/23, the RN/Executive Director/Clinical Director stated, "I meant the IDG have been meeting here in person in the office every 2 weeks". During interview 10/27/23, the Medical Director stated, "I stop by the hospice frequently sometimes daily to talk to the RN about the patients and the social worker and spiritual counselor are not present or on Zoom". During interview 10/27/23, both the Social Worker and Spiritual Counselor stated, "I have not attended a IDG at this hospice yet either in person or Zoom since we have not started IDG meetings yet". During interview 10/27/23, the RN/Executive Director/Clinical Director stated, "We have not done IDG meeting paperwork yet", "We just got a new computer system (EMR) in the past week and we have been keeping notes since we admitted patients the middle of September and plan to put the note entries into the (EMR) once we are trained", "The consultant has been training me on the new (EMR) and the rest of the staff will receive training November 1st".

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that the Interdisciplinary Group maintains responsibility for directing, coordinating, and supervising the care and services provided. This standard was not met as evidenced by document review and interview. During requests for policies and procedures, the Executive Director/Clinical Director/Registered Nurse (RN) (staff 1) was unable to access the hospice’s policies and procedures, which were stored on the computer and had to obtain assistance from the consultant to access the agency’s policies and procedures. During an interview on 10/26/2023, the Executive Director/Clinical Director/RN stated, "The policies and procedures are in the computer, but I do not know how to see them." The Executive Director/Clinical Director/RN was unable to provide copies of the hospice’s policies that define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. There was no evidence that the Executive Director/Clinical Director/RN was able to access the hospice policies and procedures, which were stored on the computer. During requests for policies and procedures, the Executive Director/Clinical Director/RN had to obtain assistance from the consultant to access policies and procedures. During interview 10/26/23, the Executive Director/Clinical Director/RN stated, "The policies and procedures are in the computer but I do not know how to see them".

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services, involves all hospice services, including those provided under contract, addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness, focuses on indicators related to improved palliative outcomes, includes investigation and analysis of sentinel and adverse events, and includes defined data detail and frequency of collection, and approves such. THIS IS A CMS CONDITION LEVEL CITATION. This condition of participation was not met as evidenced by document review and interview. Review of the Quality Assurance/Performance Improvement (QAPI) and Governing Body meeting documents revealed no documented evidence that the hospice developed and implemented a QAPI Plan and program. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse stated, "We do not have the QAPI Plan or program developed." Review of the Quality Assurance/Performance Improvement (QAPI) and Governing Body meeting documents documents revealed a missing QAPI Plan for the hospice. There was no evidence the hospice developed an QAPI Plan. During interview 10/27/23, the Executive Director/Clinical Director/RN stated, "We do not have the QAPI Plan".

It is required that Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. The hospice may contract for physician services per standard HCDT 5.I in this chapter. THIS IS A CMS CONDITION LEVEL CITATION. This condition of participation was not met as evidenced by document review, personnel record review, and interview. In 4 of 4 (100%) personnel records reviewed of staff that provide "core" services, the hospice did not ensure hospice “core” services of nursing, medical social worker, and spiritual counselor were substantially provided directly by hospice employees. Personnel Record 3: Medical Social Worker (SW) date of hire 09/28/2023. Review of the personnel record revealed the SW was not employed by the hospice agency. An offer agreement letter revealed the SW was being "paid by visit" and did not receive a W4 from the agency. During a telephone interview on 10/27/2023, the SW stated “I am not a directly hired employee, I am under agreement. The hospice does not take taxes out at the end of the year, and I did not receive a W4." Personnel Record 4: Spiritual Counselor (SC) date of hire 08/01/2023. Review of the personnel record revealed the SC was not employed by the hospice agency. An offer agreement letter revealed the SC was being "paid by visit" and did not receive a W4 from the agency. During a telephone interview on 10/27/2023, the SC stated “I am not a directly hired employee, I am under agreement. The hospice does not take taxes out at the end of the year, and I did not receive a W4.” Personnel Record 7: Nurse Practitioner (NP) /Back Up Registered Nurse (RN) date of hire 10/06/2023. Review of the personnel record revealed the NP/RN was not employed by the hospice agency. An offer agreement letter revealed the NP/RN was being "paid by visit" and did not receive a W4 from the agency. During a telephone interview on 10/27/2023, the NP/RN stated “I am not a directly hired employee, I am under agreement. The hospice does not take taxes out at the end of the year, and I did not receive a W4.” Personnel Record 1: Executive Director /Clinical Director /Registered Nurse (RN) date of hire 07/2023. A review of the personnel record revealed the NP/RN was not employed by the hospice agency. During an interview on 10/26/2023, the Executive Director /Clinical Director /RN stated, "I am not under contract or a direct employee since I am an owner and not paid yet." The Executive Director /Clinical Director /RN confirmed she is the nurse that routinely sees the patients and provides hospice nursing care and services. The agency provided no documented evidence that the hospice "core" services of the social worker, spiritual counselor, and nursing were substantially provided directly by hospice employees. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.64, Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving home health care services from the agency. There was no evidence the hospice ensured "core" services of the social worker/bereavement counselor, spiritual counselor and nurse practitioner/registered nurse were substantially provided directly by hospice employees. During phone interviews 10/27/23, the social worker/bereavement counselor, the spiritual counselor and nurse practitioner/registered nurse stated they are under agreement, not a directly hired employee, the Hospice does not take out taxes when they are paid and that they will take care of taxes themselves at the end of the year, and they were not asked to fill out a W9 or a W4. During interview 10/26/23, the Executive Director/Clinical Director/RN stated, "Everyone is under contract, the social worker, spiritual counselor and nurse practitioner, and I am not under contract or a direct employee since I am a owner and not paid yet". On 10/27/23, the Executive Director/Clinical Director/RN then stated, "The social worker, spiritual counselor and nurse practitioner are direct employees and are not contracted", "I do not have a W4 or a W9 filled out on these staff" and "an offer agreement letter was given to staff on hire". An offer agreement letter for the social worker, spiritual counselor and nurse practitioner' was included in the personnel records for being "paid by visit".

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below and the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below 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: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff, hair shampoo (sink, tub, and bed) and normal range of motion. This standard was not met as evidenced by personnel record review and interview. In 1 of 1 (100%) hospice aide personnel records reviewed, the hospice did not ensure the aide skills competency evaluation was completed for required skills. Personnel Record 5: Review of the Hospice Competency: Hospice Aide Skills Checklist dated 09/26/2023 revealed no documented evidence that the aide was competency evaluated for the skills of communication, shampoo, and normal range of motion. These items were left blank on the checklist. During an interview on 10/27/2023, the Executive Director/Clinical Director/Registered Nurse stated, this aide is performing shampoos and range of motion, and the communication and shampoo sections on the checklist are blank and have not been completed, and agreed range of motion was not listed on the checklist.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AT IMMEDIATE JEOPARDY. This condition of participation, which was also cited at Immediate Jeopardy, was not met as evidenced by review of clinical records, administrative documents, and interviews with the Executive Director /Clinical Director /Registered Nurse, which revealed issues with the organization and administration of services in the following areas: Failure to ensure a qualified Administrator /Alternate Administrator [HSLG.3.I/L651]; Failure to ensure provision of care and services for physical therapy, occupational therapy, and speech-language pathology services [HCDT.1.I/L652]; Failure to ensure staff orientation included orientation to hospice philosophy of care [HSRM.15.I/L661]; Failure to ensure employee initial orientation included infection control and organizational procedures, specific job duties, organizational policies and procedures on advanced directives [HSRM.15.I/L662]; and Failure to ensure skills competency assessments for nursing, social worker and spiritual counselor [HSRM.14.I/L663]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator is an employee of the organization, informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities, and has the education and experience as required by the governing body. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document review and interview. In 2 of 2 (100%) of personnel files reviewed for the Administrator and Alternate Administrator, the hospice governing body did not ensure the Administrator/Alternate Administrator had education and experience in hospice care. Personnel Record 1: Registered Nurse /Executive Director (Administrator)/ Clinical Director date of hire 07/2023. There was no documented evidence in the personnel record that a nursing skills competency assessment was completed. The personnel record did not include evidence of hospice general orientation and did not include orientation to hospice philosophy. The personnel record contained no evidence that the Executive Director had hospice education and/or experience. During an interview on 10/27/2023, the Registered Nurse /Executive Director /Clinical Director stated, "I do not have hospice experience” and “I am the nurse that visits the patients." Personnel Record 7: Nurse Practitioner, Back-Up Registered Nurse, Alternate Executive Director (Administrator), and Alternate Clinical Director date of hire 10/06/2023. There was no documented evidence in the personnel record that a nursing skills competency assessment was completed. The personnel record did not include evidence of hospice general orientation and did not include orientation to hospice philosophy. The personnel record contained no evidence that the Nurse Partitioner /Buck-up Registered Nurse /Alternate Executive Director had hospice education and/or experience. During an interview on 10/27/2023, the Nurse Partitioner /Buck-up Registered Nurse /Alternate Executive Director stated, "I do not have hospice experience” and “I am the back-up for the registered nurse and can provide nursing visits to patients when needed." During review of findings and interview on 10/26/2023, the Registered Nurse /Executive Director (Administrator) /Clinical Director, who is also one of the owners stated, "I have no hospice experience, only acute care and I am in the process of getting training from the consultant who comes about 1 hour a week.", The hospice did not ensure a qualified Executive Director and Alternate Executive Director were responsible for the day-to-day operations of the hospice operations. During interview 10/27/23, the Executive Director/Clinical Director and Alternate Executive Director/Alternate Clinical Director stated they do not have hospice experience. Review of the Governing Body minutes dated 7/2023 identified the "designated proxy clinical manager" who was not available at the hospice. Review of personnel records revealed missing personnel record documents on this "designated proxy clinical manager". During interview 10/26/23, the Executive Director/Clinical Director/RN who is also one of the owners stated, "I have no hospice experience, only acute care and I am in the process of getting training from the consultant who comes about 1 hour a week", and "We implemented a new computer system in the past week". Additionally, the Executive Director/Clinical Director/RN stated, "One of the other owners that is the proxy clinical manager has been (out of state) in the hospital for the past 2 months", "The third owner is out of state with a sick relative and not available", "I cannot find any personnel record documents on the proxy clinical manager" and "I now have the nurse practitioner as the back up alternate Executive Director/Clinical Director". During interview 10/27/23, the Nurse Practitioner, who is now the alternate Executive Director/Clinical Director, stated, "I do not have hospice experience".

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: Nursing services; Medical social services; Physician services; Hospice aide, Volunteer, and Homemaker services; Physical therapy, Occupational therapy, and Speech-language pathology services; Short-term inpatient care; Counseling services, including spiritual counseling, bereavement counseling, and dietary counseling; Medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by document review and interview. Review of the list of personnel, contract employee list, and personnel records provided by the Executive Director /Clinical Director /Registered Nurse (RN) during the site visit on 10/26/2023 revealed no evidence that the agency had employed physical therapy, occupational therapy, and speech-language pathology services. During an interview on 10/27/2023, the Executive Director /Clinical Director /RN stated, "We do not have a contract for or a directly hired physical therapist, occupational therapist, and speech therapist yet, but I am in process of getting a contract." The Executive Director /Clinical Director /RN confirmed the agency admitted the first patient to hospice 09/19/2023 and was not able to provide physical therapy, occupational therapy, or speech-language pathology services if required by a patient. New change of ownership effective July 2023 and first patient admitted to hospice 9/19/23. Review of personnel files and contracts revealed physical therapy, occupational therapy, and speech-language pathology services are not available to patients, if needed. During interview 10/27/23, The Executive Director/Clinical Director/RN stated, "We do not have a contract for or a directly hired physical therapist, occupational therapist, and speech therapist yet, but I am in process of getting a contract".

It is required that orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by personnel record review and interview. In 3 of 7 (43%) personnel records reviewed, the hospice did not ensure orientation to hospice philosophy was provided to employees and contracted staff who have patient and family contact. Personnel Record 2: Medical Director date of hire 08/30/2023. There was no documented evidence in the personnel record that orientation to hospice philosophy was completed. Personnel Record 4: Spiritual Counselor date of hire was 08/01/2023. There was no documented evidence in the personnel record that orientation to hospice philosophy was completed. Personnel Record 7: Nurse Practitioner /Back-Up Registered Nurse /Alternate Executive Director /Alternate Clinical Director date of hire 10/06/2023. There was no documented evidence in the personnel record that orientation to hospice philosophy was completed. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse confirmed the hospice orientation documents were not included in the personnel records. During interview 10/27/23, the Executive Director/Clinical Director/RN confirmed the missing hospice orientation documents.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation includes the following, as appropriate to the employee’s specific job duties. This standard is not met as evidenced by personnel record review and interview. In 3 of 7 (43%) personnel records reviewed, the hospice did not ensure initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Personnel Record 2: Medical Director date of hire 08/30/2023. There was no documented evidence in the personnel record that an initial orientation was completed. Personnel Record 4: Spiritual Counselor date of hire was 08/01/2023. There was no documented evidence in the personnel record that orientation to hospice philosophy was completed. Personnel Record 7: Nurse Practitioner /Back-Up Registered Nurse /Alternate Executive Director /Alternate Clinical Director date of hire 10/06/2023. There was no documented evidence in the personnel record that orientation to hospice philosophy was completed. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse confirmed the hospice orientation documents were not included in the personnel records.

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. This standard was not met as evidenced by personnel record review and interview. In 4 of 4 (100%) personnel records of employees requiring skills competency, the hospice did not ensure skills competency evaluations were completed. Personnel Record 1: Registered Nurse /Executive Director/ Clinical Director date of hire 07/2023. There was no documented evidence in the personnel record that a skills competency assessment was completed. During an interview on 10/27/2023, the Registered Nurse /Executive Director /Clinical Director stated, "I am the nurse that visits the patients." Personnel Record 3: Social Worker/Bereavement Counselor date of hire 09/28/2023. There was no documented evidence in the personnel record that a skills competency assessment was completed. Personnel Record 4: Spiritual Counselor date of hire 08/01/2023. There was no documented evidence in the personnel record that a skills competency assessment was completed. Personnel Record 7: Nurse Practitioner, Back-Up Registered Nurse, Alternate Executive Director, and Alternate Clinical Director date of hire 10/06/2023. There was no documented evidence in the personnel record that a skills competency assessment was completed. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse stated, "The missing skills competency evaluations have not been completed." During interview 10/27/23, the Executive Director/Clinical Director/RN stated, "The missing initial skills competency evaluations have not been completed".

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed, the hospice did not ensure the hospice medical director provided written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. Clinical Record 1: Patient elected hospice care on 10/10/2023. Clinical record review revealed no documented evidence that the hospice medical director or the attending physician completed an initial certification of terminal illness. The clinical record did not include documentation of an initial verbal and/or signed certification from the hospice physician that the patient had a prognosis of six months or less. The initial verbal certification form in the EMR was blank and there was no initial certification paper form in the clinical record. Clinical Record 2: Patient elected hospice care on 09/19/2023. Clinical record review revealed no documented evidence that the hospice medical director or the attending physician completed an initial certification of terminal illness. The clinical record did not include documentation of an initial verbal and/or signed certification from the hospice physician that the patient had a prognosis of six months or less. The initial verbal certification form in the EMR was blank and there was no initial certification paper form in the clinical record. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse confirmed the initial verbal and/or signed certification of terminal illness forms were not completed from the attending and the hospice physicians. During an interview on 10/27/23, the Medical Director stated, I was trained on the initial certification process in the Electronic Medical Record (EMR) on 10/26/2023 and will be completing the certifications for these patients. During interview 10/26/23, the Executive Director/Clinical Director confirmed the missing initial verbal and/or signed initial certification of terminal illness and stated, "What is a certification?" During interview 10/27/23, the Medical Director stated he was trained on the initial certification process in the Electronic Medical Record (EMR) on 10/26/23 and signed the initial certification in the EMR for (Record #3) on 10/26/23 in the EMR.

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. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AT IMMEDIATE JEOPARDY. This condition of participation, which was also cited at Immediate Jeopardy, was not met as evidenced review of clinical records and interviews with the Executive Director /Clinical Director /Registered Nurse, which revealed issues with the development and maintenance of the clinical record that contained past and current findings for each hospice patient in the following areas: Failure to ensure the patient's clinical record included plan of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided [HSIM.3.I/L672]; Failure to ensure the clinical record included the patient's response to medications, symptom management, treatments, and services [HSIM.3.I/L674]; and Failure to ensure the patient's clinical record included physician orders [HSIM.3.I/L678]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.104: Clinical Records. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed, the hospice did not ensure the patient's clinical record included plan of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. Clinical record review revealed no documented evidence that an initial plan of care had not been established for the patient. The clinical record contained no documented evidence of an initial assessment, comprehensive assessment, or updates to the plan of care and comprehensive assessment. There was no documented evidence of clinical notes by the skilled nurse, social worker or spiritual counselor. Review of the RN's personal notebook used for documenting visit notes revealed no documented notes or entries that would confirm a nursing visit occurred on 10/10/2023. During an interview on 10/27/2023, the Spiritual Counselor (staff 4) stated “I have not seen or assessed this patient.” During an interview on 10/27/2023, the Social Worker stated, “I saw the patient and completed the initial psychosocial and bereavement assessment on a paper form but have not submitted the assessment documentation to the hospice.” Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. Clinical record review revealed no documented evidence that an initial plan of care had not been established for the patient. The clinical record contained no documented evidence of an initial assessment, comprehensive assessment, or updates to the plan of care and comprehensive assessment. There was no documented evidence of clinical notes by the skilled nurse, social worker or spiritual counselor. Review of the RN's (staff 1) personal notebook, that is not part of the clinical record, used for documenting visit notes revealed a partial nursing assessment dated 09/19/2023. During an interview on 10/17/2023, the Spiritual Counselor stated, "I have seen this patient twice, once for the initial assessment and then a follow up visit, but I have not submitted the visit documentation to the hospice." During an interview on 10/27/2023, the Social Worker stated, “I saw the patient and completed the initial psychosocial and bereavement assessment on a paper form but have not submitted the assessment documentation to the hospice.” Clinical Record 3: The patient elected the hospice benefit on 10/25/2023. Clinical record review revealed no documented evidence that an initial plan of care and initial assessment had not been completed. The clinical record contained no evidence of clinical notes by the skilled nurse, social worker or spiritual counselor. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse (RN) explained the agency has purchased an electronic medical record (EMR) in the last week, but staff have not been trained yet. The Executive Director /Clinical Director /RN stated, "Staff do not enter their assessments or visit notes into the clinical record, they just keep paper forms on visits they have done, and they will add their documentation into the clinical record once they get trained on the new EMR which we just implemented in the past week." The Executive Director /Clinical Director /Registered Nurse (RN) "We have not done plans of care yet. We just got a new electronic medical record (EMR) system in the past week, and we have been keeping notes since we admitted patients in the middle of September and plan to put the note entries into the EMR once we are trained. The consultant has been training me on the new (EMR) and the rest of the staff will receive training November 1st.”

It is required that each patient’s record includes, at a minimum: Responses to medications, symptom management, treatments, and services. This standard was not met as evidence by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed, the hospice did not ensure the clinical record included the patient's response to medications, symptom management, treatments, and services. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. The clinical record contained no documented evidence of nursing visit notes with patient / family assessments, or the patient's response to medications, treatments and symptom management. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse (RN) (staff 1) stated, "I do not enter their assessments or visit notes into the clinical record. I have a notebook that I use to document nursing visits until I can be trained on the new electronic medical record (EMR) by the consultant. The consultant gave me paper forms to use but I did not use them.” Review of the RN's personal notebook used for documenting visit notes revealed no documented notes or entries that would confirm a nursing visit occurred on 10/10/23. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. The clinical record contained no documented evidence of nursing visit notes with patient / family assessments, or the patient's response to medications, treatments and symptom management. Review of the RN's (staff 1) personal notebook, that is not part of the clinical record, used for documenting visit notes revealed a partial nursing assessment dated 09/19/2023. Clinical Record 3: The patient elected the hospice benefit on 10/25/2023. The clinical record contained no documented evidence of nursing visit notes with patient / family assessments, or the patient's response to medications, treatments and symptom management. During an interview on 10/27/2023, the Executive Director /Clinical Director /RN explained the agency has purchased an electronic medical record (EMR), but staff have not been trained yet on how to enter documentation in the system. The Executive Director /Clinical Director /RN stated, "Staff do not enter their assessments or visit notes into the clinical record, they just keep paper forms on visits they have done, and they will add their documentation into the clinical record once they get trained on the new EMR which we just implemented in the past week."

It is required that each patient’s record includes, at a minimum: Physician orders. This standard is not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed, the hospice did not ensure that the patient's clinical record included physician orders. Clinical Record 1: The patient elected the hospice benefit on 10/10/2023. The clinical record contained no documented evidence of physician orders on a plan of care or physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. The medication profile listed Ativan as needed with a start date of 10/10/2023. The clinical record did not include a physician order for Ativan. During telephone interview on 10/27/2023, the patient's spouse stated they were still waiting for the patient’s blood pressure medication Lisinopril to be delivered and that the nurse and doctor told them on 10/10/2023 the patient needed to take the Lisinopril. During an interview on 10/27/2023, the Executive Director /Clinical Director /Registered Nurse (RN) stated, “I forgot to get the order and have the medications delivered. The verbal order was obtained today 10/27/2023 for Lisinopril and Ativan to be delivered today by 5:00 pm. During the interview on 10/27/2023 at 5:00 pm, the wife stated the medications were delivered to the patient. Clinical Record 2: The patient elected the hospice benefit on 09/19/2023. The clinical record contained no documented evidence of physician orders on a plan of care or physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. Clinical Record 3: The patient elected the hospice benefit on 10/25/2023. The clinical record contained no documented evidence of physician orders on a plan of care or physician orders for medications, treatments, discipline visit frequencies, diet, activity, and any other cares pertinent to the patient’s condition. During a telephone interview 10/27/2023, the patient stated, “I get short of breath when I get up and move around. I requested oxygen on Wednesday (10/25/2023), and I am still waiting for the oxygen to be delivered." During an interview on 10/27/2023, the Executive Director /Clinical Director /RN stated, "I forgot." The DME (durable medical equipment) provider was then scheduled to deliver oxygen by 3:00 pm on 10/27/2023. During a telephone interview at 3:00 pm the patient stated, "Yes, the oxygen was delivered."

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. 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 evidenced by a review of clinical records, document reviews and interviews. 3 of 5 (60%) clinical records reviewed revealed the patient or representative's signature was not obtained that he or she received a copy of the Bill of Rights and Responsibilities statement. Clinical Record 5: The patient was admitted on 8/15/22. The "Release of Information and Consent for Patient" that was signed on 8/15/22 confirming receipt of the Patient Rights and Responsibilities lacked signature by the patient's legal representative. The patient has an appointed guardian. The form was signed by the house manager that was not designated as the patient's legal representative. Clinical Record 2: The patient was admitted on 8/15/22. The "Release of Information and Consent for Patient" that was signed on 8/15/22 confirming receipt of the Patient Rights and Responsibilities lacked signature by the patient's legal representative. The patient does have a son. The form was signed by the house manager that was not designated as the patient's legal representative. Clinical Record 1: The patient was admitted on 8/15/22. The "Release of Information and Consent for Patient" that was signed on 8/15/22 confirming receipt of the Patient Rights and Responsibilities lacked signature by the patient's legal representative. The patient has an advanced directive, and not able to sign the document. The form was signed by the house manager that was not designated as the patient's legal representative. During interview on 9/14/22, the Alternate Administrator/Alternate DPCS reviewed and agreed with the findings above. Discussion was had about this regulation, with the Alternate Administrator/Alternate DPCS discussing other possible options to meet the regulation, and the importance of the legal document supporting who signs consents. Agency Policy on Rights & Responsibilities Policy #1-001.1, "Rights/Responsibilities (Revised: 9/2021)," stated in part, "5. The patient and/or representative will sign the Patient Rights and Responsibilities form confirming that he/she has received a copy of the notice."