Every finding on record at Mission Hospice Services of Los Angeles, LLC

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that the patient's plans of care included patient-specific measurable goals for the care and treatment of identified patient problems. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/27/2023, with diagnoses including malignant neoplasm of the lung and secondary malignant neoplasm of the brain. During the Interdisciplinary Group Meeting (IDG) on 11/06/2025, the nurse noted the patient was experiencing worsening weakness and contractures in her left arm and leg, which caused pain and necessitated increased doses of Norco and Voltaren Arthritis Gel. The patient's medication list included Hydrocodone/Acetaminophen 5mg-325mg, prescribed as 1 tablet every morning and at bedtime, and 1-2 tablets every 4 hours as needed for pain, and Voltaren Arthritis Pain 1% Topical Gel: 4 inches every 6 hours for pain. A review of the patient's plans of care for the benefit periods from 09/14/2025 to 11/12/2025 and 11/13/2025 to 01/11/2026 identified pain as a significant issue. The intervention documented included educating the patient and caregiver on prescribed pain management techniques. However, the only goal was for the patient and caregiver to teach back the pain management techniques, with no specific goal related to the patient's actual pain management documented. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/22/2024.On 11/10/2025, the nurse noted evidence of dysphagia in the gastrointestinal assessment and included that it had been 4 days since the patient had passed a bowel movement. A physician's order dated 11/06/2025 included Senna-S 8.6mg/50mg: 2 capsules twice daily for constipation; Lactulose 20 g/30ml: 20 g three times daily for constipation; and Dulcolax 10mg daily as needed for constipation. A review of the patient's plans of care for the benefit periods from 09/13/2025 to 11/11/2025 and 11/12/2025 to 01/10/2026 identified a problem: altered gastrointestinal status. The intervention included educating the patient and caregiver on the medications used to manage constipation. The goal identified for the treatment of the patient's constipation was to relieve or control it; however, the specific criteria for what constituted “relieved/controlled” constipation were not defined in the plan of care, rendering this goal unmeasurable. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/02/2025 with a diagnosis of Parkinson's Disease and with a comorbid condition of chronic pain syndrome. During the start of care visit documented by the Registered Nurse on 09/02/2025, she noted the patient had aching lower extremity pain that varied according to the time of day and affected her mobility and sleep/rest. The nurse documented that the patient's stated pain goal was 0/10. On 11/18/2025, the nurse noted the patient's pain score was 2/10 and that her Norco dose frequency has had to be increased. The patient's medication list included Gabapentin 100mg at bedtime for pain, Hydrocodone/Acetaminophen 5mg - 325mg: 2 tablets twice daily for pain, and Hydrocodone/Acetaminophen 10mg - 325mg: 1 tablet twice daily as needed for pain. A review of the plans of care for the benefit periods from 09/02/2025 to 11/30/2025 and 12/01/2025 to 02/28/2025 included the identified problem of pain management/altered comfort with the intervention that the nurse would educate the patient and her caregiver on when to report changes in the patient's pain and how to report those changes to the hospice. The goal for the patient's identified pain was for the patient and caregiver to understand the need to report changes in the patient's pain level to the hospice staff. There was no goal identifying the patient's pain goal, listed on admission as a goal of 0/10. During a review of the clinical record findings and an interview with the Director of Patient Care Services (DPCS) (Personnel Record 2) on 12/12/2025, she confirmed that she was working with the clinical staff to individualize the patient's problems, interventions, and goals in the plan of care. A Performance Improvement Project (PIP) for care plan specificity and measurability was initiated on 09/22/2025 with a care plan refresher class with the Registered Nurses, done on 11/20/2025. The evidence that was included in the findings was obtained after the initiation of the PIP.

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. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure updates to the patient's plans of care to reflect newly identified or worsening problems, interventions, or goals based on data from the comprehensive assessments. CLINICAL RECORD 5: The patient, who resided at home, elected the hospice benefit on 10/15/2024. During the Registered Nurse's (RN) visit on 10/14/2025, the patient's anxiety score was documented as a 5/10, with the patient reporting her anxiety goal of 1/10. Her sleeplessness was scored as 7/10, with a reported goal of 0/10. Also included was that "...Daughter reports patient is becoming more agitated and easily angered with ADLs. Lorazepam given 1-2x daily, increased insomnia. New med order...Klonopin..." The patient's medication list included Lorazepam 2mg/ml oral concentrate: 0.25ml every 6 hours PRN for anxiety as of 10/15/2024, and Klonopin 0.5mg orally at bedtime for agitation/insomnia added on 10/14/2025. Klonopin 0.5mg orally at bedtime for agitation/insomnia. The patient’s plan of care for the benefit period from 10/10/2025 to 12/08/2025 was reviewed and revealed that it was not updated to reflect the identified problems of anxiety/agitation and insomnia or any intervention or patient-specific goals addressing the patient's new/worsening anxiety, agitation, and insomnia requiring a new medication. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/27/2023, with diagnoses including malignant neoplasm of the lung and secondary malignant neoplasm of the brain. During a RN visit on 11/20/2025, the patient reported daily nausea before dinner, stating, "I am nauseous right now." The RN administered a PRN dose of Zofran, which was effective after 20 minutes. New orders were received to initiate Ondansetron 4mg daily at 4 PM for nausea management. The patient's medication list included Ondansetron 4mg every 6 hours as needed for nausea, with the daily Ondansetron 4mg disintegrating tablet added on 11/20/2025. While reviewing the patient's plan of care for the benefit period from 11/13/2025 to 01/11/2026, it was noted that the identified problem of altered nutrition and hydration had been added on 11/09/2025. However, there were no documented interventions or goals included to address the patient's worsening nausea. During a review of the clinical record findings and an interview with the Director of Patient Care Services (DPCS) (Personnel Record 2) on 12/12/2025, she confirmed that she was working with the clinical staff to individualize the patient's problems, interventions, and goals in the plan of care. A Performance Improvement Project (PIP) for care plan specificity and measurability was initiated on 09/22/2025 with a care plan refresher class with the RNs, done on 11/20/2025. The evidence that was included in the findings was obtained after the initiation of the PIP.

The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. 4 of 8 (50%) personnel records reviewed pertaining to employee infection control education, it was found that the agency failed to provide documentation confirming that all employees received the required annual or on-hire infection control training. AGENCY POLICY: The agency's policy, "Training/Inservice Education No. 1-033," included in part that, "The written plan for annual inservices will include...infection control..." PERSONNEL RECORD 2: A review of the personnel record for the Director of Patient Care Services hired on 03/17/2025 revealed that there was no infection control education documented upon hire. PERSONNEL RECORD 4: A review of the personnel record for the Registered Nurse hired on 04/18/2022 revealed that there was no documentation of infection control education for the year 2024. PERSONNEL RECORD 5: A review of the personnel record for the Social Worker hired on 10/25/2021 revealed that there was no documentation of infection control education for the year 2024. PERSONNEL RECORD 6: A review of the personnel record for the Chaplain/Bereavement Coordinator hired on 08/19/2019 revealed that there was no documentation of infection control education for the year 2024. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025 confirmed there was no documentation of infection control education provided at hire for personnel record 2, or of annual infection control education in 2024 for personnel records 4, 5, and 6. She stated that the Clinical Education team is responsible for clinical education. She noted that turnover at the corporate level in the clinical education department leadership, along with a switch to educational platforms in 2024, likely contributed to these gaps.

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 1 (100%) Hospice Aide (HA) personnel files reviewed revealed that the agency did not ensure that an annual HA supervisory visit by a Registered Nurse (RN) was documented. AGENCY POLICY: The hospice's policy "Home Health Aide Supervisory Visits No. 1-036" read in part, "...Semi-annually the registered nurse shall make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide...." PERSONNEL RECORD 7: Upon reviewing the personnel file for the Hospice Aide (HA) hired on 09/25/2023, it was found that there was no documented annual on-site supervisory visit by a RN for 2024 or to-date 2025. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025, no RN-HA Supervisory Visit for 2024 or 2025 was located in the HR file. She explained that HA supervision is conducted by the local agency, which is responsible for uploading the reports to the HA's personnel file. Due to turnover in both local clinical leadership and the corporate education team, there was no one available from the 2024 or early 2025 period to consult regarding this matter. Additionally, during an interview with the Director of Patient Care Services (DPCS) (Personnel Record 2) and the Clinical Manager (Personnel Record 11), it was stated that the previous DPCS is no longer with the agency. They could not locate any documented HA supervisory visit by a RN for 2024 and confirmed that, while a local Skills Lab Competency was completed, it did not include direct observation of the HA by a RN performing hands-on skills with a patient or pseudo-patient, nor was it conducted at the site of patient care.

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. This standard was not met as evidenced by document review and interview. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 9) on 12/11/2025, it was found that the agency's average volunteer percentage rate was 0.89% for 2024 and 0.81% to-date for 2025. These figures fall significantly below the targeted 5% of total patient care hours for all paid hospice employees and contract staff, prompting the initiation of a Performance Improvement Project (PIP) on 04/30/2025. The Volunteer Coordinator indicated Volunteer Coordinators from all corporate hospice locations meet monthly to assess ongoing activities and progress towards the volunteer engagement goal. Documented recruitment strategies include outreach via online volunteer recruitment platforms, senior fairs, health expos, and organizations such as the Lions Club and the Rotary Club. To maintain consistent engagement with current volunteers, the agency employs various methods, including calls and texts, thank-you cards, holiday and birthday greetings, and an annual gift basket or goodie bag for Volunteer Appreciation Week in April. The PIP has not yet demonstrated improvement. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 9) on 12/11/2025, it was found that the agency's average volunteer percentage rate was 0.89% for 2024 and 0.81% for 2025. These figures fall significantly below the targeted 5% of total patient care hours for all paid hospice employees and contract staff, prompting the initiation of a Performance Improvement Project on 04/30/2025. The Volunteer Coordinators from all corporate hospice locations meet monthly to assess ongoing activities and progress towards the volunteer engagement goal. Documented recruitment strategies include outreach via online volunteer recruitment platforms, senior fairs, health expos, and organizations such as the Lions Club and the Rotary Club. To maintain consistent engagement with current volunteers, the agency employs various methods, including calls and texts, thank-you cards, holiday and birthday greetings, and an annual gift basket or goodie bag for Volunteer Appreciation Week in April.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties and includes the needs and concerns of patients and families coping with a terminal illness. This standard was not met as evidenced by document review, interview and personnel record review. In 3 of 4 (75%) personnel records reviewed for employees onboarded in 2023, 2024, or 2025, it was found that the agency failed to document hospice orientation. AGENCY POLICY: "Orientation No. 1-027 states in relevant parts, "...All personnel and volunteers will be required to attend an orientation program upon employment...The orientation content for all personnel/volunteers will include...General company orientation including the organization's mission, policies and procedures, environmental safety program, etc...infection prevention and control...HIPAA regulations...Emergency management plan...A Personnel Orientation Checklist will be completed for all new personnel. New personnel will sign and date when their orientation has been completed. The supervisor will sign and date the checklist when new personnel have completed the required activities...." PERSONNEL RECORD 2: A review of the personnel record for the Director of Patient Care Services hired on 03/17/2025, revealed that there was no documentation of the completion of an initial orientation. PERSONNEL RECORD 7: A review of the personnel record for the Hospice Aide (HA) hired on 09/25/2023, revealed that there was no documentation of the completion of an initial orientation. PERSONNEL RECORD 9: A review of the personnel record for the Volunteer Coordinator hired on 04/24/2023, revealed that there was no documentation of the completion of an initial orientation. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025, hospice orientation documents for personnel records 2, 7, and 8 could not be found, despite her outreach to the Clinical Education team, who is tasked with clinical education and orientation. She noted that there had been turnover at the corporate level in the leadership of the clinical education department.

It is required that the hospice assesses the skills and competencies of all individuals providing care. This standard was not met as evidenced by document review, interview and personnel record review. In 6 of 6 (100%) applicable personnel records of clinical staff due for an annual evaluation of skills competency reviewed, it was found that the agency did not conduct the required annual evaluations of patient care staff skills, as stipulated by the agency's policy. AGENCY POLICY: The hospice's policy, "Competency Program No. 3-001," included in relevant parts, "...The organization will establish and annually evaluate a group of specific skills related to patient care/service responsibilities and complexity of care/service provided by personnel...Specific competencies will clearly identify and define the skills, which are essential to observe for determination of competence, for each job category...the essential skills will be demonstrated upon hire and annually thereafter...competency will be monitored annually...as part of the annual evaluation process...." PERSONNEL RECORD 2: A review of the personnel record for the Director of Patient Care Services hired on 03/17/2025 revealed that there was no initial Registered Nurse Competency Assessment documented upon hire. PERSONNEL RECORD 4: A review of the personnel record for the Registered Nurse hired on 04/18/2022 revealed that there was no Registered Nurse Competency Assessment documented for 2024. PERSONNEL RECORD 5: A review of the personnel record for the Social Worker hired on 10/25/2021 revealed that there was no Social Work Competency Assessment documented for 2024. PERSONNEL RECORD 6: A review of the personnel record for the Chaplain/Bereavement Coordinator hired on 08/19/2019 revealed that there was no Chaplain or Bereavement Coordinator Competency Assessment documented for 2024. PERSONNEL RECORD 7: Upon reviewing the personnel file for the Hospice Aide (HA) hired on 09/25/2023, it was found that an initial HA skills competency assessment was completed via direct observation by a RN on 10/05/2023. However, no completed HA skills competency assessment for 2024 was located. While a General Skills Lab Competency for all staff was documented on 09/10/2025, there was no evidence of the HA successfully performing grooming, hygiene, or range of motion/patient transfers under the direct observation of an RN with a patient or pseudo-patient. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025, no HA skills competency was found in the HR file, nor could it be located following her request for the Clinical Education team to search their records. She explained that there had been staff turnover at the corporate level within the clinical education department, and the process required those staff completing the HA competencies to send them to the appropriate staff to be uploaded into the HR files. Additionally, during an interview with the Director of Patient Care Services (DPCS) (Personnel Record 2) and the Clinical Manager (Personnel Record 11), it was confirmed that the previous DPCS is no longer with the agency. They could not locate a skills competency assessment for 2024 and verified that the locally completed Skills Lab Competency did not include any direct observation by an RN of hygiene, grooming, or transfer techniques utilized with a patient or pseudo-patient. PERSONNEL RECORD 8: A review of the personnel record for the Licensed Vocational Nurse hired on 02/22/2021 revealed that there was no Licensed Vocational Nurse Competency Assessment documented for 2024. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025, it was confirmed that no 2024 competency assessments were located in the HR file for personnel records 4, 5, 6, or 8, and no on-hire competency assessment was completed for personnel record 2. She explained that the previous individual in charge of the corporation's clinical education left the organization and is not available to answer questions or retrieve any documentation that may not have been scanned into the agency's electronic human resources system.

It is required that the hospice maintains an emergency preparedness(EP)training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by a review of personnel records and interviews. In 3 of 10 (30%) personnel records reviewed, the hospice did not ensure that new hospice employees and those providing services under arrangement, receive initial training in EP policies and procedures consistent with their expected roles. Personnel Record 3: (Hospice Medical Director): hire date 8/27/2019. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire and at least every two years. Personnel Record 4: (Alternate Medical Director): hire date 5/23/2019. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire and at least every two years. Personnel Record 6: (Chaplain): hire date 7/1/2021. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. The Human Resources Director was interviewed on 12/27/2022 and agreed there was no documented evidence of training in emergency preparedness policies and procedures in the records identified. The Administrator was interviewed on 12/28/2022 and confirmed this finding. Record 3 (Hospice Medical Director): hire date 8/27/2019. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire, and at least every two years. Record 4 (Alternate Medical Director): hire date 5/23/2019. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire, and at least every two years. Record 6 (Chaplain): hire date 7/1/2021. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. The Human Resources Director was interviewed on 12/27/2022 and agreed, there was no documented evidence of training in emergency preparedness policies and procedures in the records identified. The Administrator was interviewed on 12/28/2022 and confirmed this finding.

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 a review of clinical records and interviews. In 3 of 12 (25%) clinical records reviewed, the hospice did not ensure the initial spiritual assessment was completed no later than five (5) calendar days after the patients' election to hospice care. Clinical Record 2: The patient’s date of election of hospice benefits was 6/11/2022. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 4: The patient’s date of election of hospice benefits was 9/17/2022. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 7: The patient’s date of election of hospice benefits was 9/23/2022. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. The Administrator was interviewed on 12/29/2022 and agreed there was no documented evidence the initial spiritual assessments were completed no later than five days after the election of hospice care. Record 2: The patient’s date of election was 6/11/2022. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Record 4: The patient’s date of election was 9/17/2022. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Record 7: The patient’s date of election was 9/23/2022. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. The Administrator was interviewed on 12/29/2022 and agreed, there was no documented evidence the initial spiritual assessments were completed no later than five days after the election of hospice care.

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 a review of clinical records and interviews. In 6 of 12 (50%) clinical records reviewed, the hospice did not ensure that an initial bereavement assessment was completed. Clinical Record 1: The patient’s date of the election of hospice benefits was 6/24/2022. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Clinical Record 2: The patient’s date of the election of hospice benefits was 6/11/2022. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Clinical Record 3: The patient’s date of the election of hospice benefits was 3/20/2022. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Clinical Record 6: The patient’s date of the election of hospice benefits was 11/4/2022. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Clinical Record 8: The patient’s date of the election of hospice benefits was 11/2/2021. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Clinical Record 11: The patient’s date of the election of hospice benefits was 11/2/2021. There was no documented evidence a bereavement assessment was included as part of the initial assessment. The Administrator was interviewed on 12/29/2022 and agreed there was no documented evidence the bereavement assessments were completed as part of the initial assessments. Record 1: The patient’s date of election was 6/24/2022. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Record 2: The patient’s date of election was 6/11/2022. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Record 3: The patient’s date of election was 3/20/2022. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Record 6: The patient’s date of election was 11/4/2022. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Record 8: The patient’s date of election was 11/2/2021. There was no documented evidence a bereavement assessment was included as part of the initial assessment. Record 11: The patient’s date of election was 11/2/2021. There was no documented evidence a bereavement assessment was included as part of the initial assessment. The Administrator was interviewed on 12/29/2022 and agreed, there was no documented evidence the bereavement assessments were completed as part of the initial assessments.

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, includes all services necessary for the palliation and management of the terminal illness, including intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 12 (33%) clinical records reviewed, the hospice did not ensure the care plan reflected patient and family goals with defined and measurable outcomes. Clinical Record 1: The patient’s date of election of hospice benefits was 6/24/2022, with a primary diagnosis of Alzheimer’s disease. The wound record report revealed a coccyx pressure ulcer wound (#5), onset date 8/1/2022, restaged 9/6/2022 with wound care visits by a hospice nurse and wound pros. The plan of care for 9/6/2022-12/28/2022 was reviewed. The plan of care did not identify the wound as a problem or include interventions and goals to manage the wound. Clinical Record 4: The patient’s date of election of hospice benefits was 9/17/2022, with a primary diagnosis of Chronic Obstructive Pulmonary Disease. The Registered Nurse assessment on 9/17/2022 revealed O2 at 2-5L continuous for COPD/SOB. The plan of care for 9/17/2022-12/28/2022 was reviewed and stated, "Problem: Need for skilled teaching of cardiopulmonary system-hospice. Intervention: Instruct on signs/symptoms of impaired cardiac/circulatory system (increased edema, shortness of breath, cyanosis, and ways to manage/relive symptoms. Goal: Patient will have decreased edema and SOB within constraints of disease." The nursing assessment on 9/18/2022 revealed pain of 3 with a goal of 0. There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the shortness of breath, edema, and pain. Clinical Record 7: The patient’s date of election of hospice benefits was 9/23/2022, with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A review of the medication profile revealed O2 at 2L continuous for SOB, which may increase up to 5 Liters as needed for shortness of breath. The plan of care for 9/23/2022-12/28/2022 was reviewed and stated, "Problem: Altered respiratory status Goal: Patient’s respiratory status is stabilized to comfort within limitations of the disease. Problem: Need for skilled teaching of respiratory status. Goal: Patient has minimal problems with respiratory comfort." There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the shortness of breath. Clinical Record 8: The patient’s date of election of hospice benefits was 11/2/2021, with a primary diagnosis of unspecified sequelae of Cerebral Infarction. The Registered Nurse assessment on 8/12/2022 revealed pain of five in knees; start hydrocodone every morning. The Registered Nurse assessment on 8/12/2022 did not identify a patient and family goal for the pain. The plan of care for 8/12/2022-12/28/2022 was reviewed. There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the pain. The Administrator was interviewed on 12/29/2022 and agreed the plan of care reviewed did not include patient and family goals that were defined and measurable. The Administrator was interviewed on 12/29/2022 and stated, “we need to provide some education with staff on the care plans.” Record 1: The patient’s date of election was 6/24/2022 with a primary diagnosis of Alzheimer’s disease. The wound record report revealed a coccyx pressure ulcer wound (#5), onset date 8/1/2022, restaged 9/6/2022 with wound care visits by hospice nurse and wound pros. The plan of care for 9/6/2022-12/28/2022 was reviewed. The plan of care did not identify the wound as a problem or include interventions and goals to manage the wound. Record 4: The patient’s date of election was 9/17/2022 with a primary diagnosis of chronic obstructive pulmonary disease. The registered nurse assessment on 9/17/2022 revealed O2 at 2-5L continuous for COPD/SOB. The plan of care for 9/17/2022-12/28/2022 was reviewed. Problem: Need for skilled teaching of cardiopulmonary system-hospice. Intervention: Instruct on signs/symptoms of impaired cardiac/circulatory system (increased edema, shortness of breath, cyanosis, and ways to manage/relive symptoms. Goal: Patient will have decreased edema and SOB within constraints of disease. The nursing assessment on 9/18/2022 revealed pain of 3 with a goal of 0. There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the shortness of breath, edema, and pain. Record 7: The patient’s date of election was 9/23/2022 with a primary diagnosis of chronic obstructive pulmonary disease. Review of the medication profile revealed O2 at 2L continuous for SOB, may increase up to 5L as needed for shortness of breath. The plan of care for 9/23/2022-12/28/2022 was reviewed. Problem: Altered respiratory status Goal: Patient’s respiratory status is stabilized to comfort within limitations of disease. Problem: Need for skilled teaching of respiratory status. Goal: Patient has minimal problems with respiratory comfort. There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the shortness of breath. Record 8: The patient’s date of election was 11/2/2021 with a primary diagnosis of unspecified sequelae of cerebral infarction. The registered nurse assessment on 8/12/2022 revealed pain of 5 in knees, start hydrocodone every morning. The registered nurse assessment on 8/12/2022 did not identify a patient and family goal for the pain. The plan of care for 8/12/2022-12/28/2022 was reviewed. There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the pain. The Administrator was interviewed on 12/29/2022 and agreed, the plan of cares reviewed did not include patient and family goals that were defined and measurable. The Administrator was interviewed on 12/29/2022 and stated, “we need to provide some education with staff on the care plans.”

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by a review of personnel records, documents, and interviews. In 2 of 2 (100%) personnel records of contracted providers reviewed, the hospice did not ensure infection control training was provided to contracted providers, no less than annually. Agency policy, “Infection Control Plan,” stated in part, “Personnel will be provided training on the basics of transmission of pathogens to patients and personnel…no less than annually.” Personnel Record 3 (Hospice Medical Director): hire date 8/27/2019. Infection control education was documented on 8/3/2020. There was no documented evidence of infection control education in 2021 or 2022. Personnel Record 4 (Alternate Medical Director): hire date 5/23/2019. Infection control education was documented on 5/26/2019. There was no documented evidence of infection control education in 2020, 2021, or 2022. The Human Resources Director was interviewed on 12/29/2022 and agreed there was no documented evidence of annual infection control education in the records identified. The Administrator was interviewed on 12/29/2022 and confirmed the finding. Agency policy, “Infection Control Plan,” stated in part, “Personnel will be provided training on the basics of transmission of pathogens to patients and personnel…no less than annually.” Record 3 (Hospice Medical Director): hire date 8/27/2019. Infection control education was documented on 8/3/2020. There was no documented evidence of infection control education in 2021 or 2022. Record 4 (Alternate Medical Director): hire date 5/23/2019. Infection control education was documented on 5/26/2019. There was no documented evidence of infection control education in 2020, 2021 or 2022. The Human Resources Director was interviewed on 12/29/2022 and agreed, there was no documented evidence of annual infection control education in the records identified. The Administrator was interviewed on 12/29/2022 and confirmed the finding.

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 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 a review of clinical records and interviews. In 4 of 12 (33%) clinical records reviewed, the hospice did not ensure the notification of hospice non-covered items were provided to the patient within 5 days of the request upon admission. Record 3: The patient’s date of election of hospice benefits was 3/20/2022. The hospice election statement was reviewed, and identified the patient/representative requested the addendum on 3/20/2022. The patient notification of hospice non-covered items in the clinical record listed date furnished 3/26/2022, six days after the request. There was no documented evidence the notification of hospice non-covered items was provided to the patient within five days of their request at the time of admission. Record 4: The patient’s date of election of hospice benefits was 9/17/2022. The hospice election statement was reviewed, and identified the patient/representative requested the addendum on 9/17/2022. The patient notification of hospice non-covered items in the clinical record was incomplete and did not include the date furnished, signature of beneficiary/representative, or signature of hospice representative. There was no documented evidence the notification of hospice non-covered items was provided to the patient within five days of their request at the time of admission. Record 7: The patient’s date of election of hospice benefits was 9/23/2022. The hospice election statement was reviewed, and identified the patient/representative requested the addendum on 9/23/2022. The patient notification of hospice non-covered items in the clinical record was incomplete and did not include the date furnished, signature of beneficiary/representative, or signature of hospice representative. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient within five days of their request at the time of admission. Record 8: The patient’s date of election of hospice benefits was 11/2/2021. The hospice election statement was reviewed, and identified the patient/representative requested the addendum on 11/2/2021. The patient notification of hospice non-covered items in the clinical record was incomplete and did not include the date furnished, signature of beneficiary/representative, or signature of hospice representative. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. The Administrator was interviewed on 12/29/2022 and agreed there was no documented evidence the notification of hospice non-covered items was completed and provided to the patient within five days of their request at the time of admission. The Administrator stated, “we need to work on a process to get these done in time.” Record 3: The patient’s date of election was 3/20/2022. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 3/20/2022. The patient notification of hospice non-covered items in the clinical record listed date furnished 3/26/2022, 6 days after the request. There was no documented evidence the notification of hospice non-covered items was provided to the patient within 5 days of their request at the time of admission. Record 4: The patient’s date of election was 9/17/2022. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 9/17/2022. The patient notification of hospice non-covered items in the clinical record was incomplete and did not include date furnished, signature of beneficiary/representative or signature of hospice representative. There was no documented evidence the notification of hospice non-covered items was provided to the patient within 5 days of their request at the time of admission. Record 7: The patient’s date of election was 9/23/2022. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 9/23/2022. The patient notification of hospice non-covered items in the clinical record was incomplete and did not include date furnished, signature of beneficiary/representative or signature of hospice representative. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient within 5 days of their request at the time of admission. Record 8: The patient’s date of election was 11/2/2021. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 11/2/2021. The patient notification of hospice non-covered items in the clinical record was incomplete and did not include date furnished, signature of beneficiary/representative or signature of hospice representative. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. The Administrator was interviewed on 12/29/2022 and agreed, there was no documented evidence the notification of hospice non-covered items was completed and provided to the patient within 5 days of their request at the time of admission. The Administrator stated, “we need to work on a process to get these done in time.”