Every finding on record at Medica Hospice and Palliative Inc.

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 10 (20%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was reviewed and revised as frequently as the patient's condition required. Clinical Record 3: The patient elected the hospice benefit on 05/20/2024 for the diagnosis of heart failure. The initial plan of care dated 05/20/2024 included a problem for "Potential for impaired skin integrity. Goals and Interventions were to prevent skin breakdown by turning and positioning the patient." A nursing visit dated 07/15/2024 noted the patient to have a Stage III wound to her coccyx and physician orders were obtained for wound care and dressing changes. The care plan was not updated from "potential for impaired skin integrity" to "actual impaired skin integrity." The goals and interventions were not updated to include the wound care orders and dressing changes. Clinical Record 10: The patient elected the hospice benefit on 04/03/2024 for the diagnosis of senile degeneration of the brain. The initial care plan dated 04/03/2024 included the Problem: Imminent Death, although signs and symptoms did not indicate imminent death during admission. Nursing visit notes dated 05/17/2024, 05/18/2024 and 05/19/2024 indicated patient was "actively transitioning", "appeared imminent" and the "nurse was educating the family the patient was experiencing signs of dying". During this time, there were physician orders for visit frequency changes, medication changes however the Imminent Death Plan of Care was not updated to reflect the goals and interventions in the comprehensive visits. During an interview and joint record review with the Director of Patient Care Services and Alternate Director on 08/20/2024, and they stated the Plans of Care had not been updated on either Clinical Record 3 or 10 since the original plan of care were "entered by the admission nurse."

It is required that 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 5 (20%) clinical records reviewed with recertification, revealed the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. Clinical Record 3: Clinical record review revealed the sixth benefit period started on 07/19/2024 and the recertification of terminal illness was not signed by the hospice medical director on 08/12/2024, 24 days after the start of the benefit period. During an interview and joint record review with the Director of Patient Care Services and Alternate Director on 08/20/2024, it was confirmed the recertification of terminal illness had been signed "almost a month late."

It is required that a patient's clinical record contains correct clinical information that is available to the patient’s attending physician and hospice staff, including, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed revealed the agency did not ensure the clinical record contained complete physician orders. Clinical Record 3: A physician order written on 07/15/2024 stated, "clean with NS (normal saline) or skin cleaner pat dry with 4x4 gauze, apply Vaseline in the wound, wet to dry dressing in the wound, cover with adhesive foaming dressing." The order did not specify the location of the wound, who would perform the wound care, the frequency of the wound care or give any as needed orders for wound care. It was an incomplete wound care order. During an interview and joint record review with the Director of Patient Care Services and Alternate Director on 08/20/2024, it was confirmed the order lacked complete clinical information.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the patient’s current plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed in which the patient was live discharged revealed the agency did not ensure the discharge summary included at least a summary of the patient's current plan of care. Clinical Record 9: The patient elected the hospice benefit on 08/25/2023 for the diagnosis of Alzheimer's disease. The patient elected to revoke their hospice benefit on 08/19/2024. The discharge summary written on 08/19/2024 stated "Patient daughter called hospice office around 8 pm and spoke with *******. By caregiver report patient became unresponsive, skin-colored yellow, patient was drooling, and the urine color during the day was dark yellow." The discharge summary did not include the patient's current plan of care. During an interview and joint record review with the Director of Patient Care Services on 08/20/2024, it was confirmed the discharge summary did not include at least a synopsis of the patient's current plan of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. Agency Policy: Hand Hygiene Policy, No. 6-006, dated November 2022, stated in part, "Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patients, before donning sterile gloves when performing sterile procedures, before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient's intact skin (when taking a pulse, blood pressure or lifting a patient); after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated; when moving from a contaminated body site to a clean body site during patient care; after contact with inanimate objects (including medical equipment)in the immediate vicinity of the patient; and after removing gloves." Home Visit 2: During Home Visit 2 (Clinical Record 2) on 04/11/2024, the Registered Nurse (RN) (Personnel Record 5) was observed to have donned gloves, removed equipment from the bag, removed the gloves, and donned another pair of gloves. After using the equipment, the nurse changed the gloves and put the equipment back into the bag. The RN changed the gloves and assisted the caregiver with peri care. The RN changed the gloves two more times during peri care. The RN donned gloves to begin wound care. The RN changed gloves between wounds. The RN was not observed performing hand hygiene after contact with body fluids or excretions, mucous membranes, non-intact skin, wound dressings, and after removing gloves. During an interview on 04/11/2024, the Director of Nursing/Registered Nurse agreed the staff did not follow the hand hygiene policy.

It is required that a hospice must routinely provide substantially all core services directly by hospice employees. These services include nursing services, medical social services, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of personnel records review and interviews which revealed the hospice: Failed to ensure 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. A review of five core services personnel record revealed all five had W-9 forms. There was no documented evidence of any employees providing direct core services. During a personnel record review and interview on 04/12/2024, the Executive Director/Administrator confirmed that the core service staff were not direct employees but contracted staff. There was no documented evidence provided that a Waiver of Core Servies had been initiate. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation 418.64 Condition of participation: Core services The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. Clinical Record 3: The aide plan of care dated 12/20/2023 stated bed bath, assist with dressing, incontinence care, record last BM, turn, and position, passive ROM, comb hair, assist with eating, make bed, lotion, oral care, encourage fluids, elevate head after meals, change linen and tidy bathroom. The hospice aide documentation on 12/27/2023 revealed bed bath, assist with dressing, incontinence care, record last BM, turn, and position, passive ROM, comb hair, lotion, shampoo hair, back rub, assist with eating, encouraged fluids, elevate head after meals, make bed, change linen, and tidy bedroom. The documentation did not include oral care and tidy bathroom as per the plan of care. Shampoo hair, back rub, and tidy bedroom were not on the hospice aide plan of care. The hospice aide documentation on 12/29/2023 revealed bed bath, assist with dressing, incontinence care, record last BM, turn, and position, passive ROM, comb hair, lotion, shampoo hair, back rub, assist with eating, elevate head after meals, make bed, change linen, tidy bathroom, and tidy bedroom. The documentation did not include oral care and encourage fluids as per the plan of care. Shampoo hair, back rub, and tidy bedroom were not on the hospice aide plan of care. The hospice aide documentation on 01/01/2024 revealed bed bath, assist with dressing, incontinence care, turn and position, passive ROM, comb hair, lotion, shampoo hair, back rub, assist with eating, encourage fluids, elevate head after meals, make bed, change linen, and tidy bedroom. The documentation did not include oral care and tidy bathroom as per the plan of care. Shampoo hair, back rub, and tidy bedroom were not on the hospice aide plan of care. The hospice aide provided paper documentation for visits dated 01/01/2024, 01/03/2024, 01/05/2024, 01/08/2024, 01/10/2024, 01/12/2024, 01/15/2024, 01/17/2024, 01/18/2024, 01/22/2024, 01/24/2024, 01/26/2024, 01/29/2024, 01/31/2024, 02/02/2024, 02/05/2024, 02/07/2024, 02/09/2024, 01/1/2024, 02/14/2024, 02/16/2024, 02/19/2024, 02/21/2024, 02/23/2024, 02/26/2024, 02/28/2024, 03/01/2024, 03/04/2024, 03/06/2024, and 03/08/2024 revealed complete bed bath, mouth care, assist with dressing, clean hand/foot care, perineal care, apply lotion, reposition patient, activity: bed, meals: feed, set up; change bed linens, make bed, fall precautions maintained. The documentation did not include record of last BM, passive ROM, combing hair, encouraged fluids, and elevate head as per the plan of care. Clean hand/foot care and meals: set up were not on the hospice aide plan of care. During a joint record review and interview on 04/11/2024, the Director of Nursing/Registered Nurse confirmed that the records lacked evidence that the hospice aide provided services included in the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. Clinical Record 3: The aide plan of care dated 12/20/2023 stated bed bath, assist with dressing, incontinence care, record last BM, turn and position, passive ROM, comb hair, assist with eating, make bed, lotion, oral care, encourage fluids, elevate head after meals, change linen and tidy bathroom. The hospice aide documentation on 12/27/2023 revealed bed bath, assist with dressing, incontinence care, record last BM, turn and position, passive ROM, comb hair, lotion, shampoo hair, back rub, assist with eating, encouraged fluids, elevate head after meals, make bed, change linen, and tidy bedroom. The documentation did not include oral care and tidy bathroom as per the plan of care. Shampoo hair, back rub, and tidy bedroom were not on the hospice aide plan of care. The hospice aide documentation on 12/29/2023 revealed bed bath, assist with dressing, incontinence care, record last BM, turn and position, passive ROM, comb hair, lotion, shampoo hair, back rub, assist with eating, elevate head after meals, make bed, change linen, tidy bathroom, and tidy bedroom. The documentation did not include oral care and encourage fluids as per the plan of care. Shampoo hair, back rub, and tidy bedroom were not on the hospice aide plan of care. The hospice aide documentation on 01/01/2024 revealed bed bath, assist with dressing, incontinence care, turn and position, passive ROM, comb hair, lotion, shampoo hair, back rub, assist with eating, encourage fluids, elevate head after meals, make bed, change linen, and tidy bedroom. The documentation did not include oral care and tidy bathroom as per the plan of care. Shampoo hair, back rub, and tidy bedroom were not on the hospice aide plan of care. The hospice aide provided paper documentation for visits dated 01/01/2024, 01/03/2024, 01/05/2024, 01/08/2024, 01/10/2024, 01/12/2024, 01/15/2024, 01/17/2024, 01/18/2024, 01/22/2024, 01/24/2024, 01/26/2024, 01/29/2024, 01/31/2024, 02/02/2024, 02/05/2024, 02/07/2024, 02/09/2024, 01/1/2024, 02/14/2024, 02/16/2024, 02/19/2024, 02/21/2024, 02/23/2024, 02/26/2024, 02/28/2024, 03/01/2024, 03/04/2024, 03/06/2024, and 03/08/2024 revealed complete bed bath, mouth care, assist with dressing, clean hand/foot care, perineal care, apply lotion, reposition patient, activity: bed, meals: feed, set up; change bed linens, make bed, fall precautions maintained. The documentation did not include record of last BM, passive ROM, combing hair, encouraged fluids, and elevate head as per the plan of care. Clean hand/foot care and meals: set up were not on the hospice aide plan of care. The hospice aide documentation lacked notification to the registered nurse of the changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. During a joint clinical record review and interview on 04/11/2024, the Director of Nursing/Registered Nurse confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by interview and document review. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers. During an interview on 04/12/2024, the Executive Director/Administrator/Volunteer Coordinator confirmed that the retention efforts were not documented from June 2023 through March 2024. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. This standard was not met as evidenced by interview and document review. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 to March 2024. There was no documented evidence that the agency 's volunteer use did not meet the minimum, five percent (5%) of the total patient care hours. During a joint review of the volunteer program records and interview on 04/12/2024, the Executive Director/Administrator/Volunteer Coordinator confirmed that the agency did not document the direct care staff hours, the volunteer 5 % percentage, and the cost savings from January 1, 2024, through March 2024. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from June 2023 to March 2024.

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 on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by interview and personnel record review. In 2 of 10 (20%) personnel records reviewed revealed that the agency did not ensure employees received initial orientation. Personnel Record 3: The Hospice Medical Director’s date of hire was 05/11/2023. The record lacked evidence of an initial orientation. Personnel Record 4: The Alternate Medical Director’s date of hire was 06/12/2023. The record lacked evidence of an initial orientation. During a joint record review and interview on 04/12/2024, the Executive Director/Administrator confirmed that the records did not include evidence of the employee receiving initial orientation.

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 revealed that the agency did not ensure employees were assessed for skills and competencies. Personnel Record 3: The Medical Director's date of hire was 05/11/2023. The record lacked evidence of assessing skills and competencies. Personnel Record 4: The Alternate Medical Director's date of hire date of hire was 06/12/2023. The record lacked evidence of assessing skills and competencies. During a joint record review and interview on 04/12/2024, the Executive Director/Administrator/Volunteer Coordinator confirmed that the records did not include evidence that the employees were assessed for skills and competencies.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed revealed the agency did not ensure the patient’s record includes physician’s orders. Clinical Record 3: The hospice aide plan of care was created on 12/20/2024. The hospice aide made visits on 12/20/2024, 12/22/2023, 12/25/2023, 12/27/2023, 12/29/2023, and 01/01/2024. The record lacked a physician's order for the aide services from 12/20/2024 to 01/01/2024. During a joint review of the record and an interview on 04/11/2024, the Clinical Director/Registered Nurse confirmed that the records lacked evidence of physician's orders for the hospice aide visits.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 8 (25%) clinical records reviewed revealed that the agency did not ensure that all entries in the patient record were legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. Agency Policy: Clinical/Service Data Collection Policy No. 6-022, dated November 2022, stated in part, "Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include what care/service was provided, treatment and/or invasive procedures performed, patient response to treatment and/or procedures, the date the service was provided (month, day, year), and the signature of clinician/technician and his/her credentials." Clinical Record 3: The Hospice Aide visits were scheduled three times a week, starting from 12/20/2023. However, there were significant gaps in the documentation for the weeks of 01/21/2024-01/27/2024, 01/28/2024-02/03/2024, 02/04/2024-02/10/2024, 02/11/2024-02/17/2024, 02/18/2024-02/24/2024, 02/25/2024-03/02/2024, 03/03/2024-03/09/2024, 03/10/2024-03/16/2024, 03/17/2024-03/23/3034, 03/24/2024-03/30/2024, 03/31/2024-04/06/2024. During the site visit, the Hospice Aide provided paper copies of weekly notes from 01/01/2024 through 03/09/2024, but these notes had partial dates and lacked the year on all documents. During the clinical record review, it was discovered that the Hospice Aide had reentered previously documented notes in the EMR and changed the documented interventions provided to the patient for visits dated 12/20/2023 through 03/09/2024. The aide plan of care dated 12/20/2023 stated bed bath, assist with dressing, incontinence care, record last BM, turn and position, passive ROM, comb hair, assist with eating, make bed, lotion, oral care, encourage fluids, elevate head after meals, change linen and tidy bathroom. The hospice aide provided paper documentation for visits dated 01/01/2024, 01/03/2024, 01/05/2024, 01/08/2024, 01/10/2024, 01/12/2024, 01/15/2024, 01/17/2024, 01/18/2024, 01/22/2024, 01/24/2024, 01/26/2024, 01/29/2024, 01/31/2024, 02/02/2024, 02/05/2024, 02/07/2024, 02/09/2024, 01/1/2024, 02/14/2024, 02/16/2024, 02/19/2024, 02/21/2024, 02/23/2024, 02/26/2024, 02/28/2024, 03/01/2024, 03/04/2024, 03/06/2024, and 03/08/2024 revealed complete bed bath, mouth care, assist with dressing, clean hand/foot care, perineal care, apply lotion, reposition patient, activity: bed, meals: feed, set up; change bed linens, make bed, fall precautions maintained. The documentation did not include a record of the last BM, passive ROM, combing hair, encouraged fluids, and elevating the head as per the plan of care. Clean hand/foot care and meals: set up were not on the hospice aide plan of care. When reviewing the record with the Director of Nursing/Registered Nurse, the documentation entered into the electronic record indicated that the hospice aide completed all of the interventions on the hospice aide plan of care and not what was documented on the paper documentation as to what had happened. Clinical Record 8: The Skilled Nurse PRN Visit dated 03/19/2024 (discharge visit) had not been started in the EMR or on paper. A joint clinical record review and interview with the Executive Director/Administrator/Volunteer Coordinator occurred on 04/11/2024. The Executive Director/Administrator/Volunteer Coordinator stated that she managed all documentation, paper, and electronic, for the staff. When asked about the location of the missing documentation, the Executive Director/Administrator/Volunteer Coordinator stated that the Hospice Aide documented it in the electronic record and on paper for the visits. The Executive Director/Administrator/Volunteer Coordinator confirmed that the documentation was not in the electronic or paper records. The Executive Director/Administrator/Volunteer Coordinator contacted the Hospice Aide for the documentation. Upon reviewing the findings with the Director of Nursing/Registered Nurse, the Executive Director/Administrator/Volunteer Coordinator stated that she instructed the Hospice Aide to enter the electronic record to complete her documentation. The Executive Director/Administrator/Volunteer Coordinator stated that she reopened the documentation for the Hospice Aide to complete as far back as 12/20/2024. When the documentation was viewed in the electronic record, all of the documented Hospice Aide visit notes stated they were waiting for approval. The Hospice Aide visit notes were dated the day of the visit as opposed to entered as a late entry. All visits were verified with the Executive Director/Administrator/Volunteer Coordinator to have been made by the registered nurse and hospice aide. During a joint record review and interview with the Director of Nursing/Registered Nurse on 04/11/2024, it was discovered that the Hospice Aide had entered the electronic record and changed the documentation on the notes as indicated above. The timeframe was approximately two to three hours from the initial record review until the review with the Director of Nursing/Registered Nurse. The Director of Nursing/Registered Nurse was made aware of what the documentation stated and viewed what the documentation stated during the review.

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 and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 8: The date of the revocation was 03/19/2024. The record lacked documentation that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 04/11/2024, the Director of Nursing/Registered Nurse confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.