Every finding on record at Maestro Hospice Care LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed, it was revealed that the agency did not ensure that the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. Clinical Record 1: The patient elected hospice care on 11/13/2024. The Registered Nurse completed the nursing comprehensive assessment on 11/13/2024. The nursing assessment did not include documentation of a spiritual assessment. The Spiritual Counselor (SC) completed the spiritual assessment on 11/24/2024, eleven days after the election of hospice care. There was no documentation in the clinical record explaining the delay. The Medical Social Worker (MSW) attempted to complete the psychosocial assessment on 11/27/2024, but the patient declined the visit. There were no further documented MSW visits. There was no documentation in the clinical record explaining the delay. Additionally, there was no documentation in the record notifying the physician of the declined visit. The Administrator (Personnel Record 1) was interviewed on 12/04/2024 and stated that the MSW and SC did not document why there was a delay in completing the comprehensive assessments.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed, the agency did not ensure that all services that were ordered on the plan of care were provided to the patient. Clinical Record 1: The Plan of Care (POC) dated 11/13/2024 contained an order for Skilled Nursing (SN) services with a frequency and duration of 3w9. Two SN visits were documented as provided during the first week of care. There was no documentation in the record that the physician was notified of the missed visit. The Administrator (Personnel Record 1) was interviewed on 12/05/2024 and stated, "The patient was to be seen every Monday, Wednesday, and Friday. The frequency should have been for two visits the first week." Clinical Record 3: The Plan of Care (POC) dated 03/20/2022 included a visit order and frequency for the Volunteer Coordinator (VC) of 1mo3. On 12/26/2022, the VC documented a note that the patient declined volunteer services. There was no further documentation in the clinical record of the VC contacting the patient offering volunteer services. Additionally, there was no documentation in the record of communication to the ordering physician that the patient declined volunteer services or that the ordered services on the POC dated 03/20/2022 were not provided. The Administrator (Personnel Record 1) was interviewed on 12/05/2024 and stated, "We thought that every patient needed to have an order for Volunteer services, even if they declined it so that the Volunteer Coordinator could continue to follow up with the patient and family."

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visit observation performed, it was revealed that the agency did not ensure that clinical staff performed hand hygiene per the agency's policy. Document 1: The agency policy titled, Hand Hygiene (undated), stated in part, "Field staff providing care/services in the home setting will cleanse their hands: Upon arrival in the client's home or work area, before and after gloves are used." Home Visit 1: During the home visit with the Registered Nurse (RN) (Personnel Record 5) on 12/05/2024, the RN was observed washing her hands with soap and water upon entry into the home. The RN then put on gloves and entered the clinical bag to remove a blood pressure cuff, thermometer, and barrier. The RN then used hand sanitizer on her gloved hands. After laying out the needed equipment on the barrier, the RN removed her gloves. The RN did not perform hand hygiene after glove removal. The RN left the home to retrieve a stethoscope from her car. The RN did not perform hand hygiene when she re-entered the patient's home. The RN put on another pair of gloves to perform a physical assessment. The RN did not perform hand hygiene before putting gloves on or after removing them. The RN was interviewed on 12/06/2024 and stated, "I know I had some problems with my hand hygiene at the visit yesterday."

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. In 2 of 10 (20%) personnel records reviewed, it was revealed that the agency did not ensure that the competencies were performed per the agency's policy. Document 1: The agency policy titled, Clinical Competency Evaluation, (undated), stated in part, "All direct care patient employees and contracted staff will receive competency testing at time of hire, prior to unsupervised direct patient service, annually, and at other points as deemed necessary by supervisors. Skills competency testing will be performed by a like discipline." Personnel Record 6: The Medical Social Worker personnel record documented competencies dated 12/22/2021, 12/22/2022, and 12/22/2023. Each of these competencies was signed by the Director of Clinical Services, not by a like discipline. Personnel Record 9: The Chaplain personnel record documented competencies dated 03/15/2021, 03/15/2022, 03/15/2023, 03/15/2024. Each of these competencies was signed by the Director of Clinical Services, not by a like discipline. The Administrator (Personnel Record 1) was interviewed on 12/06/2024 and stated, "I didn't realize that competencies needed to be done by the same discipline as the employee."

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. The physician considers the following when making this determination: The primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed it was revealed that the agency did not ensure that the attending physician included narrative documentation on the Certification of Terminal Illness (CTI) related to the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, or information about the medical management of any of the patient's conditions unrelated to the terminal illness. Clinical Record 1: A review of the clinical record revealed that the CTI dated 11/20/2024 only contained the statement, " I certify that [patient] is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course." The CTI did not contain a physician narrative to support terminal illness. The Medical Director (Personnel Record 3) was interviewed on 12/05/2024 and stated, "I need to add more narrative documentation on the CTI to support the terminal illness."

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record of a patient that was receiving care after the initial benefit period, it was revealed that the agency did not ensure that the recertification certification of terminal illness (CTI) included a physician narrative to support the terminal illness. Clinical Record 2: The CTI for the recertification of hospice services dated 10/21/2024 only contained the statement, " I certify that [patient] is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course." The CTI did not contain a physician narrative to support the ongoing certification of the terminal illness. The Medical Director (Personnel Record 3) was interviewed on 12/05/2024 and stated, "I need to add more narrative documentation on the CTI to support the terminal illness."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Any advance directives. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's advanced directives were accurately documented in the clinical record. Clinical Record 1: A clinical record review revealed that the patient elected the hospice benefit on 11/13/2024. The Do Not Resuscitate (DNR) consent form signed and dated on 11/13/2024 did not indicate a selection for full code or for DNR status. There was a note on the side of the form that documented, "continuing discussion" as well as documentation in the clinical note that stated, "The family was not ready to sign the DNR." The plan of care (POC) dated 11/13/2024 contained an order that the patient was a DNR. There was also an alert in the medical record that indicated that the patient was a DNR. The Administrator (Personnel Record 1) was interviewed on 12/05/2024 and stated, "The DNR form was not completed completely or accurately."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of a patient was discharged from hospice service, it was revealed that the agency did not ensure that a discharge summary was provided to the patient’s attending physician. Clinical Record 3: A review of the clinical record revealed that the patient was discharged from hospice on 05/04/2022 because the patient was "no longer terminally ill." There was no discharge summary present in the clinical record and no documentation that the patient's attending physician had been notified of the discharge. The Administrator (Personnel Record 1) was interviewed on 12/05/2024 and stated that she reviewed the clinical record and confirmed that no discharge summary was present and sent to the physician and that there was no documentation of communication with the physician.

It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by clinical record review and interview. 3 of 5 (60%) clinical records reviewed revealed the records did not have documented advance directives. Record #25868 was reviewed and identified that the patient elected the hospice benefit on 3/9/2020. The consents state that family was not ready to sign DNR. The Plan Of Care created on 12/27/2021 stated the patient was a DNR. Record #25062 was reviewed and identified that the patient elected the hospice benefit on 1/18/2019. There was no documented advance directive in the clinical record. Record #93094 was reviewed and identified that the patient elected the hospice benefit on 1/16/2019. There was no documented advance directive in the clinical record. The Director of Nursing was interviewed on 1/20/2022 and agreed that the plan of care is not accurate, the patient remains a full code. She had no additional information to provide.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: The types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical records reviewed with beareavement services revealed that bereavement services were not provided per a written Plan Of Care. Record #12938 was reviewed and identified that the patient died on 2/13/2021. There was no Bereavement Plan of Care present in the record. The Bereavement Coordinator was interviewed on 1/19/2022 and described all of the services that were being provided to the bereaved family; however, she agreed that there is not a plan of care developed in the clinical record.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 1 of 4 (25%) applicable clinical records of patients with an order for hospice aide services reviewed revealed no aide plan of care in place. Record #25062 was reviewed and identified the patient was admitted on 1/18/2019 An order was written on 1/18/2019 for hospice aide services two time a week. There is no aide plan of care in record. The Director of Nurses was interviewed on 1/19/2022 and agreed that the aide plan of care was missing. She had no additional information to provide.

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. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) applicable clinical records with volunteer services ordered revealed that volunteer services were not provided per the Plan Of Care. Record #32170 was reviewed and identified that the patient was admitted on 12/20/2021. The Volunteer Coordinator met with the family on 12/26/2021 to review services. The family declined volunteer services at that time. The visit frequencies remained on the plan of care for volunteer services at one time a month. The Director of Nursing was interviewed on 1/19/2022 and confirmed this finding.

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. The physician considers the following when making this determination: The primary terminal condition; related diagnosis(es), if any; current subjective and objective medical findings; current medication and treatment orders; information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by 5 of 5 (100%) clinical records reviewed revealed missing physician narrative of clinical information for Certification of Terminal Illness (CTI). Record #25868 was reviewed and identified the patient was admitted on 3/9/2020. There was no physician narrative present on the initial CTI. Record #32170 was reviewed and identified the patient was admitted on 12/20/2021. There was no physician narrative present on the initial CTI. Record #25062 was reviewed and identified the patient was admitted on 1/18/2019. There was no physician narrative present on the initial CTI. Record #93094 was reviewed and identified the patient was admitted on 1/16/2019. There was no physician narrative present on the initial CTI. Record #12938 was reviewed and identified the patient was admitted on 1/28/2020. There was no physician narrative present on the initial CTI. The Director of Nursing was interviewed on 1/18/2022 and agreed that there was no narrative statement on the CTI. Education was provided regarding the minimum information that should be present in the narrative statement. She had no additional information to provide.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. 4 of 5 (80%) clinical records reviewed revealed that the signed copies of hospice election statement were not completed accurately. Record #25868 was reviewed and identified that the patient elected the hospice benefit on 2/9/2020. There was no effective date present on the consent and the reason the patient cannot sign was listed as "unable". Record #32170 was reviewed and identified that the patient elected the hospice benefit on 12/20/2021. There was no effective date present on the NOE and there was no documentation that the patient/poa was provided with a notice of Covered/non Covered items. Record #93094 was reviewed and identified that the patient elected the hospice benefit on 1/16/2019. There was no effective date present on the consents and no reason was provided for why the patient was unable to sign the consent. The Director of Nursing was interviewed on 1/19/2022. She agreed that there were errors on the consents and had no additional information to provide,

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information and recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) applicable recertification clinical record reviewed revealed that the physician certification/recert of terminal illness (CTI) was not completed as required. Record #25868 was reviewed and identified that the patient elected the hospice benefit on 2/9/2020. There were no CTIs created/completed for the 10 recertified benefit periods: 6/7/2020, 9/5/2020, 11/4/2020, 1/3/2021, 3/4/2021, 5//3/2021, 7/2/2021, 8/31/2021, 10/30/2021 and 12/29/2021. The Director of Nursing was interviewed on 1/19/2022 and agreed that there was no narrative statement on the CTI. She had no additional information to provide.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records reviewed with discharges revealed no documented evidence of a discharge summary. Record #93094 was reviewed and identified that the patient discharged from hospice on 2/3/2019. There was no discharge summary present in the clinical record and no documentation that the patient's attending physician had been notified. Record #25063 was reviewed and identified that the patient discharged from hospice on 4/15/2019. There was no discharge summary present in the clinical record and no documentation that the patient's attending physician had been notified. The Director of Nursing was interviewed on 1/19/2022 and agreed that there was no documentation of communication with the attending physician in the clinical record and had no additional information to provide.