Every finding on record at Munson Home Care

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. This standard was not met as evidenced by clinical record review and interview. In 1 of 26 (4%) clinical records reviewed, the agency did not ensure that the hospice drug profile contained all current prescription medications. Clinical Record 3: Election of benefit 6/1/22 with a terminal diagnosis of Alzheimer's Disease. RN visit note on 7/11/23 documented, "patient agrees and takes the antibiotics dose as prescribed, per staff she refused the past two days." A physician order, from 7/6/23, for 'Cephalexin 500mg capsule, take one capsule two times daily for urinary tract infection' was located. The drug profile, effective from 7/6/23 to current, did not contain evidence that Cephalexin had been added. During the interview on 7/27/23, the Quality Improvement Nurse reported the physician's order had been sent to the pharmacy, and the medication was provided to the patient. However, the nurse did not enter the medication into the hospice drug profile.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 6 of 26 (23%) clinical records reviewed, the agency did not ensure the plan of care included the goals and interventions specific to problems that were identified within the comprehensive assessments of the patient. Clinical Record 6: Election of hospice benefit 10/27/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The RN comprehensive assessment, dated 6/12/23, documented under the fall risk assessment, "prior falls within last three months? YES" and "risk score = 10 according to the MAHC 10 fall risk assessment this patient is at risk of falling." The nurse practitioner's face-to-face visit on 6/22/23 stated, "unsteady, poor balance, weakness, high risk for falls." The care plan, effective 10/27/22 to current, did not include any problems, goals, or interventions related to safety needs or fall prevention. Clinical Record 11: Election of hospice benefit on 6/24/23 with a terminal diagnosis of Pulmonary Fibrosis. The Initial nursing comprehensive assessment (6/24/23) documented "abnormal breath sounds, dyspnea on exertion, cough and oxygen at 4 liters." The plan of care, effective from 6/24/23 to current, did not document any respiratory problems, goals, or interventions, Clinical Record 12: Election of hospice benefit on 2/3/23 with a terminal diagnosis of Hypertensive Heart Disease with Chronic Kidney Disease. The RN comprehensive assessment, dated 4/25/23, documented "reason for pain/stiffness: recent fall" and "according to the MAHC 10 fall risk assessment, this patient's score is 7; based on the score, the patient is: at risk for falling." The plan of care, effective from 2/3/23 to current, did not document any problems, goals, or interventions related to safety or fall prevention. Clinical Record 15: Election of benefit 5/14/22 with a terminal diagnosis of Acute Respiratory Failure. The RN comprehensive assessment, dated 4/24/23, stated, "did have a fall over the weekend, no new injuries noted." Physician narrative, dated 4/28/23, reported, "5 falls in the last month." The plan of care, effective from 5/14/22 to current, did not document any problems, goals, or interventions related to safety or fall prevention. Clinical Record 16: Election of benefit 4/20/23 with a terminal diagnosis of Amyotrophic Lateral Sclerosis (ALS). Initial nursing comprehensive assessment (4/20/23) documented, "disease progressing, the patient declined PEG (percutaneous endoscopic gastrostomy) tube and tracheostomy...dysphagia diet, thickened liquids." The Physician narrative, dated 4/24/23, documented "has chronic dysphagia" and "he needs all his medicines crushed. He is on thickened liquids. He chronically aspirates." The plan of care, effective from 4/20/23 to current, did not document any problems, goals, or interventions related to dysphagia, aspiration precautions, or dietary modifications. Clinical Record 17: Election of benefit 7/18/23 with a terminal diagnosis of Congestive Heart Failure (CHF). RN's initial comprehensive assessment (7/18/23) documented, "wife reports he did have a fall approximately three weeks ago" and "according to the MAHC 10 fall risk assessment, this patient's score is 7; based on the score the patient is: at risk for falling." The plan of care, effective from 7/18/23 to current, did not document any problems, goals, or interventions related to safety or fall prevention. The Quality Improvement Nurse reviewed the clinical records, including the plans of care, and confirmed, during the interview on 7/27/23, that there should have been specific care planned interventions for these identified problems.

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. In 4 of 18 (22%) clinical records reviewed, in which aide services were accepted, the agency did not ensure that RN provided specific care instructions for the hospice aide care plans, thus leaving the aides to make decisions outside their scope of practice. Clinical Record 1: Election of benefit 11/15/22. The aide care plan, effective from 5/4/23 to current, listed the following relevant tasks; "transfer client from bed/chair as needed" and "perineal care as needed." The care plan did not provide further information for the aide to determine when the tasks would be needed. Clinical Record 8: Election of benefit 7/24/23. The aide care plan, effective from 7/24/23 to current, listed the following relevant tasks: "bathing-bed bath; may give shower if tolerated," "bathing-shower; may give bed bath if the shower is not tolerated," and "oral care daily, as needed." The care plan did not provide further information for the aide to determine when the tasks would be needed. Clinical Record 16: Election of benefit 4/20/23. Diagnoses included Amyotrophic Lateral Sclerosis (ALS) and dysphagia. The aide care plan, effective from 4/21/23 to current, listed the following relevant tasks: "diet: soft/moist food, avoid dry foods, thickened liquids as tolerated." The care plan did not include specific instructions on the consistency the liquids needed to be thickened to, nor did it include aspiration precautions. Clinical Record 25: Election of benefit 11/22/22. The aide care plan, effective from 11/22/22 to the patient's death on 12/12/22, listed the following relevant tasks: "bathing- bed bath every visit, as needed"; and "turn and position in bed every visit, as needed." The care plan did not provide further information for the aide to determine when the tasks would be needed. The Quality Improvement Nurse reviewed the records in question and confirmed, during an interview on 7/27/23, that the aide care plans were not specific enough. It was further stated that this had been a recent focus of internal reviews.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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, document review, and interview. In 22 of 26 (85%) clinical records reviewed, in which the patients were Medicare beneficiaries, the agency's election of benefits statement did not contain the required elements (effective as of October 1, 2020) set forth under Condition of Participation 418.24(b). Condition of Participation 418.24 stated in the relevant part: "(b) Content of election statement. The election statement must include the following: (3) Acknowledgement that the individual has been provided information on the hospice's coverage responsibility and that certain Medicare services, as set forth in paragraph (e) of this section, are waived by the election. For Hospice elections beginning on or after October 1, 2020, this would include providing the individual with information indicating that services unrelated to the terminal illness and related conditions are exceptional and unusual and hospice should provide virtually all care needed by the individual who has elected hospice. (5) For Hospice elections beginning on or after October 1, 2020, the Hospice must provide information on individual cost-sharing for hospice services. (6) For Hospice elections beginning on or after October 1, 2020, the Hospice must provide notification of the individual's (or representative's) right to receive an election statement addendum, as set forth in paragraph (c) of this section, if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual's terminal illness and related conditions and would not be covered by the hospice. (7) For Hospice elections beginning on or after October 1, 2020, the Hospice must provide information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information." The agency electronic document titled "Informed Consent and Election of Benefit Authorizations and Consents" did not include the information listed above. The agency had a paper document titled, "Hospice Coverage and Right to Request 'Patient Notification of Hospice Non-Covered Items, Services, and Drugs'" that contained the information regarding requesting the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum. This was a stand-alone form, and this information was not part of the election statement. Furthermore, none of the records reviewed contained evidence that this form had been provided to the patient or family. This impacted all Medicare patients under review, and all Medicare patients admitted since 10/1/2020. The agency presented evidence that within the initial nursing assessment, the nurse is prompted to ask, "Does the patient or their representative request to receive the "Patient Notification of Hospice Non-Covered Items, Services and Drugs?" However, it was identified that while this question appears for the nurse to ask during the admission assessment, the question/answer does not become a part of the final initial nursing comprehensive assessment document; in other words, the question is asked, answered, and then disappears from the clinical documentation. However, if the answer was "yes," it sent the request to the office to complete the addendum. One patient under review, had indicated "YES," and the agency presented the completed addendum. The booklet provided to patients at the time of admission did not contain any information on the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" nor the QIO information. The patient bill of rights document contained relevant information, "Financial: Patients have the right to: receive information about the services covered under the hospice benefit." Clinical Record 1: Election of hospice Medicare benefit 11/15/22. Clinical Record 3: Election of hospice Medicare benefit 6/1/22. Clinical Record 4: Election of hospice Medicare benefit 7/20/23. Clinical Record 6: Election of hospice Medicare benefit 6/24/23. Clinical Record 7: Election of hospice Medicare benefit 4/29/23. Clinical Record 8: Election of hospice Medicare benefit 7/24/23. Clinical Record 9: Election of hospice Medicare benefit 5/5/23. Clinical Record 10: Election of hospice Medicare benefit 7/18/23. The patient had requested the addendum upon admission, and a completed and signed document was produced as evidence it had been provided. Clinical Record 11: Election of hospice Medicare benefit 6/24/23. Clinical Record 12: Election of hospice Medicare benefit 2/3/23. Clinical Record 13: Election of hospice Medicare benefit 4/18/23. Clinical Record 14: Election of hospice Medicare benefit 1/25/22. Clinical Record 15: Election of hospice Medicare benefit 5/14/22. Clinical Record 16: Election of hospice Medicare benefit 4/20/23. Clinical Record 17: Election of hospice Medicare benefit 7/18/23. Clinical Record 19: Election of hospice Medicare benefit 6/26/23. Clinical Record 20: Election of hospice Medicare benefit 5/5/23. Clinical Record 21: Election of hospice Medicare benefit 6/10/23. Clinical Record 22: Election of hospice Medicare benefit 5/25/23. Clinical Record 23: Election of hospice Medicare benefit 7/29/22. Clinical Record 24: Election of hospice Medicare benefit 4/21/22. Clinical Record 25: Election of hospice Medicare benefit 11/22/22. Interviews were conducted with the Clinical Supervisor and the Regional Director throughout the site visit regarding this process. The summary of the finding/evidence occurred on 7/27/23, where both staff members confirmed that the election statement did not contain the required language. The Clinical Manager indicated that they thought it had been included in the electronic version but upon review, agreed it was not present. The management team was asked for the agency policy on the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs"; however, the Regional Director reported that there was not one. The patient admission booklet and patient bill of rights were reviewed with the Clinical Manager, who confirmed that neither of these documents addressed the non-covered items nor provided the QIO information. It was stated that no additional documents were presented to the patient/representatives that would contain this information. Condition of Participation 418.24 stated in relevant part: "(b) Content of election statement. The election statement must include the following: (3) Acknowledgement that the individual has been provided information on the hospice's coverage responsibility and that certain Medicare services, as set forth in paragraph (e) of this section, are waived by the election. For Hospice elections beginning on or after October 1, 2020, this would include providing the individual with information indicating that services unrelated to the terminal illness and related conditions are exceptional and unusual and hospice should be providing virtually all care needed by the individual who has elected hospice. (5) For Hospice elections beginning on or after October 1, 2020, the Hospice must provide information on individual cost-sharing for hospice services. (6) For Hospice elections beginning on or after October 1, 2020, the Hospice must provide notification of the individual's (or representative's) right to receive an election statement addendum, as set forth in paragraph (c) of this section, if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual's terminal illness and related conditions and would not be covered by the hospice. (7) For Hospice elections beginning on or after October 1, 2020, the Hospice must provide information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information." The agency electronic document titled, "Informed Consent and Election of Benefit Authorizations and Consents" did not include the information listed above. The agency had a paper document titled, "Hospice Coverage and Right to Request 'Patient Notification of Hospice Non-Covered Items, Services, and Drugs'" that contained the information regarding requesting the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum. This was a stand-alone form, and this information was not part of the election statement, furthermore, none of the records reviewed contained evidence that this form had been provided to the patient or family. This impacted all Medicare patients under review as well as all Medicare patients admitted since 10/1/2020. The agency presented evidence that within the initial nursing assessment the nurse is prompted to ask, "Does the patient or their representative request to receive the "Patient Notification of Hospice Non-Covered Items, Services and Drugs?" However, it was identified that while this question appears for the nurse to ask during the admission assessment the question/answer do not become a part of the final initial nursing comprehensive assessment document; in other words, the question is asked, answered, and then disappears from the clinical documentation. However, if the answer was "yes" it sent the request to the office to complete the addendum. One patient, under review, had apparently indicated "YES" and the agency presented the completed addendum.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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, interview, and observation. In 3 of 26 (12%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders for all medications and treatments provided to the patient. Clinical Record 4/Home Visit 4: Election of benefit 7/20/23. During the home visit observation on 7/26/23, the hospice nurse asked the facility nurse about the wound dressing changes. The facility said, "The dressing change is ordered every five days, but the dressing rolls up, so it is practically changed daily." The plan of care, effective from 7/20/23, listed "provide wound care per orders." The hospice clinical record did not include physician orders for dressing changes or wound care. Clinical Record 8/IPU visit 2: Election of benefit 7/24/23. During the home visit observation on 7/26/23, the patient had oxygen at 2 liters per nasal cannula. The hospice clinical record did not include orders for oxygen, nor was it listed on the drug profile. Clinical Record 11: Election of benefit 6/24/23. RN's initial comprehensive assessment (6/24/23) documented the patient was on oxygen at 4 liters. RN visit note from 7/21/23 documented the patient still utilized oxygen at 4 liters. The hospice clinical record did not include orders for oxygen, nor was it listed on the drug profile. On 7/27/23, the Quality Improvement Nurse reported no physician orders for these items. It was further said that the agency had "oxygen 1-5 liters as needed for shortness of breath" as a standing order, but for it to become an "active order," the nurse needed to include it on the drug profile and this was not done.

It is required that each patient room in the hospice facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by document review, interview, and observation. In 1 of 1 (100%) in-patient units toured by the Site Visitor, the agency did not ensure the water supply used by patients was tested to meet state regulatory guidance. Life Safety regulations, Hospice and Hospice Residents: Hospice Residents Water Temperature requirement, as defined in part R 325.13517, Water Systems Rule 517 number 3, "A hospice shall ensure that tempered water is regulated in the range between 105 and 120 degrees Fahrenheit". Observation 2: During the Life Safety Code observation, on 7/26/23, with the Facilities Maintenance Director and Clinical Supervisor (staff 1), it was revealed that documented temperature logs had not been maintained to ensure an adequate supply of hot water to the patient rooms. A spot check of two patient rooms (sink and shower), water temperatures indicated ranges of 100-102 degrees. Each room did have a mixing valve for water control. During the interview (7/26/23) with the Facility Maintenance Director and the Clinical Supervisor, it was reported that the hospice had not been documenting the water temperatures.

It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by document review, interview, and observation. In 1 of 1 (100%) in-patient units (IPU) toured by the Site Visitor, the agency did not ensure the temperature of food for daily patient meals was tested with results documented. The Agency policy stated in relevant parts, "A. Microwave ovens tend to cook unevenly and leave cold spots where harmful bacteria can survive. For this reason, it is important to use a food thermometer and test food in several places to ensure it has reached the recommended safe temperature to destroy bacteria and other pathogens that could cause foodborne illness. B. Before serving or eating food, the temperature of the food must always be checked to ensure that it has reached 165 degrees for a minimum of 15 seconds, and you are to stir the food and let it stand for a minimum of two minutes after removing from the microwave before eating or serving to prevent burn injury." Through observation and interview, during the IPU Life Safety Code visit on 7/26/2023, with the Facility Maintenance Director and the Clinical Supervisor, both confirmed that temperature logs could not be presented for food that was prepared and cooked or reheated in a microwave oven at the facility before delivery to the patient. The clinical supervisor (staff 1) reported that the facility staff used the microwave to prepare breakfast, reheat meals brought from the hospital kitchen (if needed), and for snacks throughout the day, per patient request. Furthermore, the clinical supervisor reported on 7/27/23 that the hospital kitchen did not have food temperature testing documented before delivering the food to the in-patient units. Thus the food had not been tested at any point before patient consumption.

It is required that the hospice inpatient facility provides meals to each patient that are stored under sanitary conditions. This standard was not met as evidenced by document review, interview, and observation. In 1 of 1 (100%) in-patient units (IPU) toured by the Site Visitor, the agency did not ensure that frozen foods used for patient consumption were packaged and dated correctly. The Agency policy is stated in the relevant part, "Section A. #12. All perishable foods are to be labeled, dated, and refrigerated until prepared or served. All foods that are opened need to have a use by and discard date." Observation 2: Facility observation conducted on 7/26/23 revealed the following frozen food items in the unit's kitchen where staff prepare patient foods: one open package of bacon, one unopened package of bacon, one opened package of sausage, and one unopened package of sausage. These four frozen items were not labeled with "use by" or "discard by" dates, and no expiration dates could be identified. During an interview on 7/26/2023 with the Facility Maintenance Director and the Clinical Supervisor, both confirmed that the packages did not contain the proper labels and should have been dated.