Every finding on record at Neogen Care Hospice

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. Document 1: On 9/26/2023, the DPCS provided a binder titled Emergency Preparedness for review. The binder did not include a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. During the wrap-up conference on 9/26/2023, the Administrator stated that she was not aware that a documented risk assessment using an "all-hazards" approach was required in order to develop an emergency preparedness plan. "We know our risks in the area for earthquakes and fires and we do a fire drill in the office twice per year. I didn't know more was needed."

It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that patients were involved in the development of the plan of care. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient was not included in the development of the plan of care or plan of care updates as none were developed during the course of the patient's care. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient was not included in the development of the plan of care or plan of care updates as none were developed during the course of the patient's care. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient was not included in the development of the plan of care or plan of care updates as none were developed during the course of the patient's care. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient was not included in the development of the plan of care or plan of care updates as none were developed during the course of the patient's care. During the exit conference on 9/28/2023, the Administrator confirmed that patients were not included in the development of plans of care for Records 1, 2, 3, and 4 as no plans of care was developed for these patients during the time period that each was receiving services from the hospice.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. This CONDITION was not met as evidenced by clinical record review and interview which revealed issues related to the initial and comprehensive assessment of patients in the following areas: Failure to ensure initial comprehensive assessments were being completed no later than five (5) calendar days after the election of hospice care [HCPC.9.I/L523]; Failure to ensure comprehensive assessments were performed initially or at recertification in order to identify the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness [HCPC.10.I/L524]; Failure to ensure that all initial and updated comprehensive assessments included a drug profile that contained the patient's current medications with documented evidence of medication review [HCPC.15.I/L530]; Failure to ensure that initial comprehensive assessment included an initial bereavement assessment [HCPC.14.I/L531]; Failure to ensure that the update of the comprehensive assessment was completed no less frequently than every 15 days [HCPC.17/I/L533] and Failure to ensure that data elements of each patient's comprehensive assessment were documented and retrievable for each patient to be used in individual care planning and in aggregate for the hospice's quality assessment and performance improvement program [HCPC.16.I/L535]. The cumulative effect of these deficiencies resulted in the hospice's inability to ensure the provision of quality of care. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice service from the agency. This led to a determination of Immediate Jeopardy at the Condition of Participation CFR 418.54: Initial and Comprehensive assessment of the patient.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) start of care records reviewed, the hospice did not ensure that an initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence of an initial medical social worker evaluation, an initial spiritual counselor evaluation, or an initial bereavement assessment. There was no documentation that the patient was offered the services or that the patient refused the services. The DPCS stated that he was unable to locate documented evidence of the offer, acceptance, or decline of a medical social worker, a spiritual counselor, or an initial bereavement assessment or that the evaluations/assessment had been performed for Record 4.

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s: well-being; comfort; dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure comprehensive assessments were performed initially or at recertification in order to identify the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. A joint clinical record review with the DPCS on 9/26/2023 revealed that the initial assessment was only "plotted" for the RN to document the initial assessment on 12/17/2021 but the initial comprehensive assessment was not documented. The DPCS stated, "It's blank. I don't know why." Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented recertification assessment in benefit period 10 (4/26/2023-6/24/2023), prior to benefit period 11 effective 6/25/2023. The DPCS stated, "I don't know why it wasn't done." Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the initial assessment was only "plotted" for the RN to document the initial assessment on 7/5/2022 but the initial comprehensive assessment was not completed with all assessment items blank. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the initial assessment was only "plotted" for the RN to document the initial assessment on 9/15/2022 but the initial comprehensive assessment was not completed with all assessment items blank. On 9/26/23, the DPCS reviewed the electronic records then confirmed that he was unable to locate documented evidence of initial assessments for Records, 1,3, and 4, and no documented evidence of a recertification assessment that was completed for Record 2 that identified the physical, psychosocial, emotional, and spiritual needs related to the patient's terminal illness.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that all initial and updated comprehensive assessments included a drug profile that contained the patient's current medications and documented evidence of medication review. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed no documented comprehensive assessments from the start of care to discharge included a drug profile or a review of any medications. The DPCS confirmed that there was no initial comprehensive assessment documented in the electronic medical record (EMR) at the start of care on 12/17/2021. The recertification assessment documented on 4/10/2023 was blank in the medication section of the assessment document. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed there was no updated comprehensive assessment documented in benefit period 10 (4/26/2023-6/24/2023) and therefore no updated drug profile and medication review documented. The DPCS also confirmed there was no comprehensive assessment documented in benefit period 11 from 6/25 up to and including no discharge assessment and therefore no medication profiles or medication reviews in the patient's final benefit period before live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed no documented comprehensive assessments from the start of care to discharge and no drug profile or a review of any medications. The DPCS confirmed that there was no initial comprehensive assessment documented in the electronic medical record (EMR) at the start of care on 7/5/2022. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no completed initial comprehensive assessment and therefore no drug profile or medication review completed as a part of the comprehensive assessment. The DPCS stated that most patient records were created in the EMR, and paper records were uploaded and attached to the EMR. The DPCS stated that he was unable to locate documented evidence of drug profiles and medication reviews completed as a part of the comprehensive assessments for Records 1, 2, 3, and 4 in the EMR on 9/26/23.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the hospice failed to ensure that the initial comprehensive assessment included an initial bereavement assessment. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence of an initial bereavement assessment. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence of an initial bereavement assessment. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence of an initial bereavement assessment. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence of an initial bereavement assessment. The DPCS confirmed initial comprehensive assessments did not include initial bereavement assessments for Records 1, 2, 3, and 4.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed, the hospice did not ensure that the update of the comprehensive assessment was completed no less frequently than every 15 days. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed no evidence of an updated comprehensive assessment during the patient's 10th benefit period (4/26/2023-6/24/2023). The record included twice weekly LVN skilled nursing visit notes and no RN comprehensive assessment visit notes between 4/26/2023 and 6/24/2023. The DPCS confirmed that there were no RN comprehensive assessments documented in the patient's electronic medical record between 4/26/2023 and 6/24/23. "There isn't even an RN recertification assessment for the next benefit period [benefit period 11, effective 6/25/2023.]"

The hospice measures and documents data in the same way for all patients. The data elements are used for each patient in individualized care planning and coordination of services. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that the data elements of each patient's comprehensive assessment were documented and retrievable for each patient to be used in individual care planning and in aggregate for the hospice's quality assessment and performance improvement program. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that an initial comprehensive assessment was not documented on 12/17/2021 and was blank. The DPCS confirmed that data elements for the comprehensive assessment documented on 12/17/2021 were not documented and could not be retrieved for completion of the plan of care or for use in analyzing the organization's quality or performance. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. A joint clinical record review with the DPCS on 9/26/2023 revealed that the updated comprehensive recertification assessment was not documented during benefit period 10 (4/26/2023-6/24/2023) and was blank. The DPCS confirmed that the data elements for the updated comprehensive assessment were not documented and could not be retrieved for completion of the plan of care or for use in analyzing the organization's quality or performance. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the initial comprehensive assessment was not documented on 7/5/2022 and was blank. The DPCS confirmed that the data elements for the initial comprehensive assessment were not documented and could not be retrieved for completion of the plan of care or for use in analyzing the organization's quality or performance. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the initial comprehensive assessment was not documented on 9/15/2022 and was blank. The DPCS confirmed that the data elements for the initial comprehensive assessment were not documented and could not be retrieved for completion of the plan of care or for use in analyzing the organization's quality or performance. The DPCS stated he was unable to locate complete comprehensive assessments for Records 1, 2, 3, and 4 and confirmed that data elements for all patient comprehensive assessments could not be used in individual care planning and in aggregate for the hospice's quality assessment and performance improvement program.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This CONDITION was not met as evidenced by clinical record review, document review and interview which revealed issues related to the completion and documentation of the patients’ Plans of Care in the following areas: Failure of the hospice to designate a registered nurse member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care [HCPC.19.I/L540]; Failure of the hospice to ensure that care and services provided to patients and families followed the individualized plan of care established by the hospice IDG [HCPC.19.I/L543]; Failure to ensure each patient had a plan of care that included education and training to be provided by the hospice [HCPC.20.I/L544]; Failure to ensure that written individualized plans of care were developed and reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments [HCPC.21.I/L545]; Failure to ensure individualized written plan of care (POC) included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs [HCPC.21.I/L547]; Failure to ensure that each patient’s individualized written plan of care included drugs and treatment necessary to meet the needs of the patient [HCPC.21.I/L548]; Failure to ensure plans of care included drugs and treatment necessary to meet the needs of the patient [HCPC.21.I/L549]; Failure to ensure plans of care included all medical supplies and appliances necessary to meet the needs of the patient [HCPC.21.I/L550]; Failure to ensure the interdisciplinary group (IDG) documented the patient’s or representative’s level of understanding, involvement, and agreement with the plan of care [HCPC.21.I/L551]; Failure to ensure the IDG reviewed, revised and documented the individualized plan as frequently as the patient’s condition required, but no less frequently than every 15 calendar days [HCPC.22.I/L552] and failure to ensure that plans of care were revised to include information from the patient's updated comprehensive assessment and the patient’s progress toward outcomes and goals [HCPC.22.I/L553]. The cumulative effect of these deficiencies resulted in the hospice's inability to ensure the provision of quality of care at the Condition of Participation CFR 418.56: Interdisciplinary group, care planning, and coordination of services. The provision of care and services in the absence of prepared written plans of care for each patient led to an Immediate Jeopardy determination being made at this CONDITION LEVEL - 418.56.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure continuous assessment of each patient’s and family’s needs, and to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) of clinical records reviewed, the hospice did not ensure a Registered Nurse was designated to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no RN initial assessment documented at the start of care on 12/17/2021 in order to establish and implement an interdisciplinary plan of care; and no evidence that an RN ensured continuous assessment that led to implementation of interdisciplinary plan of care updates documented as no plans of care were documented for any benefit period throughout the patient's course of care and services from the start of care through live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the RN did not ensure that an updated comprehensive assessment prior to the 10th benefit period (effective 4/26/2023-6/24/2023) led to the establishment and implementation of an interdisciplinary plan of care. It was also revealed that there was no RN recertification assessment documented during the patient's 10th benefit period (4/26/2023-6/24/2023) in order to establish and implement a subsequent interdisciplinary plan of care for benefit period 11 (effective 6/25/2023.) The DPCS confirmed that the RN did not ensure continuous assessment and development of the interdisciplinary plan of care for benefit periods 9, 10, or 11. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no RN initial assessment documented at the start of care on 7/5/2022 in order to establish and implement an interdisciplinary plan of care; and no evidence that an RN ensured continuous assessment that led to implementation of interdisciplinary plan of care updates documented for either benefit period from the start of care through live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no RN initial assessment documented at the start of care on 9/15/2022 in order to establish and implement an interdisciplinary plan of care; and no evidence that an RN ensured continuous assessment throughout the benefit period that led to interdisciplinary plan of care updates from the start of care up to the patient's death. The DPCS confirmed that there was no documented evidence in Records 1, 2, 3, and 4 that an RN member of the IDG ensured continuous assessment and implementation of interdisciplinary plans of care.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no individualized plan of care established by the hospice IDG at any time during the patient's course of care. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no individualized plan of care established by the hospice IDG at any time during the patient's course of care. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no individualized plan of care established by the hospice IDG at any time during the patient's course of care. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no individualized plan of care established by the hospice IDG at any time during the patient's course of care. The DPCS signed into the electronic medical record (EMR) using his username and password and was navigating the EMR using his credentials during the joint clinical record review on 9/26/23. The DPCS confirmed that the EMR did not include evidence of documented individualized hospice plans of care established by the hospice IDG for Records 1, 2, 3, or 4.

It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that each patient had a plan of care that included education and training to be provided by the hospice. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient did not have a plan of care that included education and training that would be provided by the hospice at any time during the patient's course of care. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient did not have a plan of care that included education and training that would be provided by the hospice at any time during the patient's course of care. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient did not have a plan of care that included education and training that would be provided by the hospice at any time during the patient's course of care. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient did not have a plan of care that included education and training that would be provided by the hospice at any time during the patient's course of care. The DPCS stated that he was unable to locate documented evidence of plans of care that included education and training that would be provided by the hospice established at any point in the patient's care for Records 1, 2, 3, or 4.

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; and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the hospice did not ensure the development of individualized written plans of care for each patient that reflected patient and family goals; planned interventions based on problems identified in initial and updated comprehensive assessments. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of individualized written plans of care that contained goals, interventions, or any of the services necessary to manage the patient's terminal illness throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that contained goals, interventions, or any of the services necessary to manage the patient's terminal illness throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that contained goals, interventions, or any of the services necessary to manage the patient's terminal illness throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that contained goals, interventions, or any of the services necessary to manage the patient's terminal illness throughout the entire course of the patient's start of care up to the patient's death. During the exit conference, the administrator presented a plan of care that had been documented on 9/27/2023 and was unsigned by a nurse or by the hospice medical director. The administrator confirmed that the written plan of care had been developed on 9/27/2023, which was after the patient's care and services had been provided from 9/15/2022 to 11/28/2022. The DPCS stated that he was unable to locate any documented evidence of individualized written plans of care that contained goals, interventions, or any of the services necessary to manage the patient's terminal illness for Records 1, 2, 3, or 4 that had been documented while the patients were receiving services from the hospice.

It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the hospice did not ensure that each patient’s individualized written plan of care (POC) included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs throughout the entire course of the patient's start of care up to the patient's death. The DPCS stated that he was unable to locate any documented evidence of individualized written plans of care that included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs for Records 1, 2, 3, or 4 that had been documented while the patients were receiving services from the hospice.

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. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that each patient’s individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of individualized written plans of care that contained measurable outcomes anticipated from implementing and coordinating the plan of care throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of individualized written plans of care that contained measurable outcomes anticipated from implementing and coordinating the plan of care throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that contained measurable outcomes anticipated from implementing and coordinating the plan of care throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that contained measurable outcomes anticipated from implementing and coordinating the plan of care throughout the entire course of the patient's start of care up to the patient's death. The DPCS stated that he was unable to locate any documented evidence of individualized written plans of care that contained measurable outcomes anticipated from implementing and coordinating the plan of care for Records 1, 2, 3, or 4 that had been documented while the patients were receiving services from the hospice.

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that each patient’s individualized written plan of care included drugs and treatment necessary to meet the needs of the patient. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included drugs and treatment necessary to meet the needs of the patient throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included drugs and treatment necessary to meet the needs of the patient throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included drugs and treatment necessary to meet the needs of the patient throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included drugs and treatment necessary to meet the needs of the patient throughout the entire course of the patient's start of care up to the patient's death. The DPCS stated that he was unable to locate any documented evidence of individualized written plans of care that contained drugs and treatment necessary to meet the needs of the patient for Records 1, 2, 3, or 4 that had been documented while the patients were receiving services from the hospice.

It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that each patient’s individualized written plan of care included medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included medical supplies and appliances necessary to meet the needs of the patient throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included medical supplies and appliances necessary to meet the needs of the patient throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included medical supplies and appliances necessary to meet the needs of the patient throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included medical supplies and appliances necessary to meet the needs of the patient throughout the entire course of the patient's start of care up to the patient's death. The DPCS stated that he was unable to locate any documented evidence of individualized written plans of care that included medical supplies and appliances necessary to meet the needs of the patient for Records 1, 2, 3, or 4 that had been documented while the patients were receiving services from the hospice.

It is required that each patient’s individualized written plan of care includes the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that each patient’s individualized written plan of care (POC) included the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC throughout the entire course of the patient's start of care through the patient's live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of any individualized written plans of care that included the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC throughout the entire course of the patient's start of care up to the patient's death. The DPCS stated that he was unable to locate any documented evidence of individualized written plans of care that included the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC for Records 1, 2, 3, or 4 while the patients were receiving services from the hospice.

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 4 of 4 (100%) clinical records reviewed, the organization did not ensure that the Interdisciplinary Group (IDG) reviewed, revised, and documented the individualized care plan as frequently as the patient's condition required; but no less frequently than every 15 calendar days. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the IDG reviewed, revised, or documented an individualized plan of care or plan of care updates no less frequently than every 15 calendar days or at any time during the patient's course of care and services. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the IDG reviewed, revised, or documented an individualized plan of care or plan of care updates no less frequently than every 15 calendar days or at any time during the patient's course of care and services. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the IDG reviewed, revised, or documented an individualized plan of care or plan of care updates no less frequently than every 15 calendar days or at any time during the patient's course of care and services. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the IDG reviewed, revised, or documented an individualized plan of care or plan of care updates no less frequently than every 15 calendar days or at any time during the patient's course of care and services. The DPCS did not produce documented evidence that the IDG reviewed, revised, or documented an individualized plan of care or plan of care updates no less frequently than every 15 calendar days for Records 1, 2, 3, or 4 during the site visit.

It is required that a revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that a revised plan of care was documented that included information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that any revised plans of care were documented that included information from an updated comprehensive assessment and there was no documentation of the patient's progress toward any established outcomes or goals at any time during the patient's course of care and services. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that any revised plans of care were documented that included information from an updated comprehensive assessment and there was no documentation of the patient's progress toward any established outcomes or goals at any time during the patient's course of care and services. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that any revised plans of care were documented that included information from any updated comprehensive assessments and there was no documentation of the patient's progress toward any established outcomes or goals at any time during the patient's course of care and services. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that any revised plans of care were documented that included information from any updated comprehensive assessments and there was no documentation of the patient's progress toward any established outcomes or goals at any time during the patient's course of care and services. The DPCS did not produce documented evidence any plans of care had been established or revised that included information from any updated comprehensive assessments for Records 1, 2, 3, or 4. The DPCS also did not produce any documented evidence for Records 1, 2, 3, or 4 of patient progress toward outcomes or goals as no outcomes of goals were specified in written plans of care.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments; developing and evaluating the plan of care; and contributing to patient and family counseling and education. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that licensed professionals actively participated in all aspects of patient care. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of physician orders or development of an Interdisciplinary Group (IDG) plan of care and no documented IDG plan of care reviews throughout the course of care and services from the start of care through live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of ongoing interdisciplinary assessments including no recertification assessment in benefit period 10 (4/26/2023-6/24/2023); no documented evidence of physician orders or development of an IDG plan of care throughout the course of care and services from the start of care through live discharge; and no documented IDG plan of care reviews throughout the course of care and services from the start of care through live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of the development of an IDG plan of care and no evidence of IDG plan of care reviews throughout the course of care and services from the start of care through live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of the development of an IDG plan of care and no documented evidence of IDG plan of care reviews throughout the course of care and services from the start of care up to the patient's death. The DPCS signed into the electronic medical record (EMR) using his username and password and was navigating the EMR using his credentials during the joint clinical record review on 9/26/23. The DPCS stated that most patient records were created in the EMR, and paper records were uploaded and attached to the EMR. The DPCS confirmed that he was unable to locate documented evidence of that licensed professionals actively participated in all aspects of patients care as described for Records 1, 2, 3, and 4.

It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. The hospice may contract for physician services per standard HCDT 5.I in this chapter. This CONDITION was not met as evidenced by clinical record review, document review and interview which revealed issues related to the provision of core services as follows: Failure to ensure that the hospice medical director served as a physician member of the IDG or the hospice medical director himself participated in the plan of care development, review, or revision throughout the course of the patient's care and services [HCDT.5.I/L590]; Failure to ensure that nursing care and services were provided under the supervision of a registered nurse [HCDT.6.I/L591]; Failure to ensure the development of a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery [HCDT.22.I/L596] and failure to ensure that that patients and families were advised of spiritual counseling services to meet these needs in accordance with the patient’s and family’s acceptance of this service [HCDT.11.I/L598]. The cumulative effect of these deficiencies resulted in the hospice's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice service from the agency.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that the hospice medical director, also serving as the physician member of the IDG, was responsible for the palliation and management of patients' terminal illness as well as conditions related to the terminal illness. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of identification of the patient's terminal illness and related conditions in an IDG plan of care, as there was no documented IDG plan of care. There was no documented evidence that the hospice medical director served as a physician member of the IDG or the hospice medical director himself participated in the plan of care development, review, or revision throughout the course of the patient's care and services. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of identification of the patient's terminal illness and related conditions in an IDG plan of care, as there was no documented IDG plan of care. There was no documented evidence that the hospice medical director served as a physician member of the IDG, or the hospice medical director himself participated in the plan of care development, review, or revision throughout the course of the patient's care and services. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of identification of the patient's terminal illness and related conditions in an IDG plan of care, as there was no documented IDG plan of care. There was no documented evidence that the hospice medical director served as a physician member of the IDG, or the hospice medical director himself participated in the plan of care development, review, or revision throughout the course of the patient's care and services. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of identification of the patient's terminal illness and related conditions in an IDG plan of care, as there was no documented IDG plan of care. There was no documented evidence that the hospice medical director served as a physician member of the IDG, or that the hospice medical director himself participated in the plan of care development, review, or revision throughout the course of the patient's care and services. The DPCS was signed into the electronic medical record (EMR) using his username and password and was navigating the EMR using his credentials on 9/26/2023. The DPCS confirmed that there was no documented evidence that the hospice medical director served as a physician member of the IDG that took part in the development, review, or revision of IDG plans of care for Records 1, 2, 3, or 4.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and document review. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that nursing needs of the patient were met as identified in initial or updated comprehensive assessments and included in the plan of care. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that no nursing needs identified in any of the comprehensive assessments were identified in a written plan of care or plan of care update as there were no documented plans of care from throughout the course of care and services from the start of care through live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that no nursing needs identified in any of the comprehensive assessments were identified in a written plan of care or plan of care update as there were no documented plans of care from throughout the course of care and services from the start of care through live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that no nursing needs identified in any of the comprehensive assessments were identified in a written plan of care or plan of care updates since there were no documented plans of care from throughout the course of care and services from the start of care through live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that no nursing needs identified in any of the comprehensive assessments were documented in a written plan of care or plan of care update as there were no plans of care from throughout the course of care and services from the start of care up to the patient's death. The DPCS stated that clinical records 1, 2, 3, and 4 did not contain documented evidence of plans of care, and therefore nursing needs that were identified in the comprehensive assessments performed throughout the course of care from the start of care up to the patient's death could not have been determined to be met.

It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which a patient was discharged due to death, the hospice did not ensure the development of a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery. Clinical Record 4: The patient died on hospice services on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the clinical record contained no documented evidence of a bereavement plan of care. The DPCS confirmed that the patient's record did not contain evidence of a post-death bereavement assessment of the patient's family or caregivers, no documented bereavement plan, services offered or provided, and no documentation of refusal of bereavement services.

It is required that counseling services include spiritual counseling. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed, it was revealed that the organization did not ensure that the hospice advised the patient and family of spiritual counseling services and did not document the acceptance or refusal of services. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the record contained no documented evidence that the patient and family had been offered spiritual counseling services, or whether or not they accepted or refused spiritual counseling services at the start of care, during the second benefit period of care, or at any time throughout the course of care. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the record contained no documented evidence that the patient and family had been offered spiritual counseling services, or whether or not they accepted or refused spiritual counseling services at the start of care, or at any time throughout the course of care up to the patient's death. The DPCS signed into the electronic medical record (EMR) using his username and password and was navigating the EMR using his credentials during the joint clinical record review on 9/26/23. The DPCS stated that most patient records were created in the EMR, and paper records were uploaded and attached to the EMR. The DPCS was unable to locate documented evidence of the offer, acceptance, or decline of spiritual counseling services in Records 3 and 4.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records in which aide services were provided, the hospice did not ensure that a registered nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the IDG meet the patient's need. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. During a joint clinical record review with the DPCS it was revealed that the record contained evidence of aide visits that were documented three times per week in the patient's tenth (10) benefit period effective 4/26/2023 through 6/24/2023. There were no documented Registered Nurse (RN) visits for the entire 10th benefit period (4/26/2023-6/24/2023). The DPCS agreed that there were no documented RN visits that included supervision of aide services performed at least every 14 days during the patient's tenth (10) benefit period.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. This CONDITION was not met as evidenced by document review and interview. The agency failed as follows: to ensure that the hospice managed and administered its resources to provide hospice services to patients, caregivers, and families for the palliation and management of terminal illness and related conditions. The governing body failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement activity HSLG.2.I/L651]. An Immediate Jeopardy (IJ) determination was made at this CONDITION LEVEL - 481.100.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation and provision of care and services. This standard was not met as evidenced by document review and interview. Document 2: On 9/26/2023, the DPCS provided a binder for review titled Governing Body. The binder contained no documentation to support that the hospice's overall status of operations and provision of care and services had been reviewed in 2021, 2022, or 2023. The binder contained no documentation for 2021, 2022, or 2023 that included information about the ongoing operations of the organization including no information pertaining to patient care coordination and delivery issues such as missed comprehensive assessments, missing plans of care, missed Interdisciplinary Group (IDG) meetings to review and revise plans of care, and missing physician narratives of initial and recertification of terminal illness. On 9/28/23 prior to the exit conference the Administrator stated there was no additional information to be provided that included documentation of the Governing Body's review of the hospice's operations and care and services provided. "I am not just the administrator I am an owner, so I already know what is happening with the hospice every day."

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. This CONDITION was not met as evidenced by clinical record review and interview; the hospice agency failed to ensure the following: that the hospice medical director provided written certification that it was anticipated that the patient’s life expectancy was 6 months or less if the illness runs its normal course [HCPC.4.I/L667]; that the hospice medical director provided a written and signed recertification of terminal illness that was informed by a review of patient clinical information HCPC.6.I/L668] and that the hospice medical director assumed responsibility for the medical component of the hospice's patient care program [HCPC.4.I/L669]. The cumulative effect of these deficiencies resulted in the hospice's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.102: Medical Director. The failure of the hospice to ensure that the responsibilities of the medical director for the medical component of the hospice’s patient care program were being discharged, led to an Immediate Jeopardy determination being made at this CONDITION LEVEL - 418.102.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition; related diagnosis(es), if any; current subjective and objective medical findings; current medication and treatment orders; information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that the hospice medical director provided written certification that it was anticipated that the patient's life expectancy would be six months or less if the illness ran its normal course. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient record contained no documented evidence of the hospice medical director's written certification of the patient's terminal illness that it was anticipated that the patient's life expectancy would be six months or less if the illness ran its normal course at the start of care or prior to any subsequent benefit periods (benefit periods 2 through 9). Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient record contained no documented evidence of the hospice medical director's written certification of the patient's terminal illness that it was anticipated that the patient's life expectancy would be six months or less if the illness ran its normal course at the start of care. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient record contained no documented evidence of the hospice medical director's written certification of the patient's terminal illness that it was anticipated that the patient's life expectancy would be six months or less if the illness ran its normal course at the start of care or prior to any subsequent benefit periods (benefit periods 2 through 11). Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient record contained no documented evidence of the hospice medical director's written certification of the patient's terminal illness that it was anticipated that the patient's life expectancy would be six months or less if the illness ran its normal course at the start of care or prior to the second benefit period. The Administrator stated that she contacted both the former and current medical directors who had responsibility for the hospice's patient care program since the organization's initial deemed survey. The Administrator confirmed that neither hospice medical director had documented evidence of any written certifications of terminal illness for any applicable timepoints for Records 1, 2, 3, or 4.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records in which the patient received services in more than one benefit period, the organization did not ensure that the hospice medical director provided a written and signed recertification of terminal illness that was informed by a review of patient clinical information. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the hospice medical director was informed of the patient's clinical information in order to write and then sign recertification of the terminal illness prior to each of the patient's benefit periods (benefit periods 3-9). The record contained no documented evidence of clinical information provided for the medical director's review and there was no documented evidence of Face-to-Face visits performed by the medical director prior to the patient's third through ninth benefit periods. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the hospice medical director was informed of the patient's clinical information in order to write and then sign recertification of the terminal illness prior to each of the patient's benefit periods (benefit periods 3-11). The record contained no documented evidence of clinical information provided for the medical director's review and there was no documented evidence of Face-to-Face visits performed by the medical director prior to the patient's third through eleventh benefit periods. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the hospice medical director was informed of the patient's clinical information in order to write and then sign a recertification of the terminal illness prior to the patient's second benefit period. The record contained no documented evidence of clinical information provided for the medical director's review. The Administrator stated that she contacted both the former and current medical directors who had responsibility for the hospice's patient care program since the organization's initial deemed survey. The Administrator agreed that neither hospice medical director had documented evidence of clinical information reviewed or Face-to-Face visits performed, as applicable, and no copies of written and signed recertifications of terminal illness for Records 1, 2, 3, or 4.

It is required that the medical director or physician designee has responsibility for the medical component of the hospice's patient care program. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that the medical director assumed responsibility for the medical component of the hospice's patient care program. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the hospice medical director did not oversee the implementation of the entire nursing, social work, therapy, and counseling areas consistently to meet patient and family needs. The patient record contained no documented evidence of the hospice medical director's review of clinical information that was then used to narrate initial certification or recertification of terminal illness at required time points throughout the patient's course of care through live discharge. There was no documented evidence that the physician participated with the Interdisciplinary Group (IDG) to develop or update the patient's plan of care to ensure that patient and family needs were being met at the start of care and at least every 15 days up to the point of the patient's live discharge. There was no documented evidence that the hospice medical director was consulted, reviewed clinical information, and agreed that the patient was no longer eligible for services and should be discharged. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the hospice medical director did not oversee the implementation of the entire nursing, social work, therapy, and counseling areas consistently to meet patient and family needs. The patient record contained no documented evidence of the hospice medical director's review of clinical information that was then used to narrate initial certification or recertification of terminal illness at required time points throughout the patient's course of care through live discharge. There was no documented evidence that the physician participated with the Interdisciplinary Group (IDG) to develop or update the patient's plan of care to ensure that patient and family needs were being met at the start of care and at least every 15 days up to the point of the patient's live discharge. There was no documented evidence that the hospice medical director was consulted, reviewed clinical information, and agreed that the patient was no longer eligible for services and should be discharged. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the hospice medical director did not oversee the implementation of the entire nursing, social work, therapy, and counseling areas consistently to meet patient and family needs. The patient record contained no documented evidence of the hospice medical director's review of clinical information that was then used to narrate initial certification or recertification of terminal illness prior to the patient's second benefit period. There was no documented evidence that the physician participated with the Interdisciplinary Group (IDG) to develop or update the patient's plan of care to ensure that patient and family needs were being met at the start of care and at least every 15 days up to the point of the patient's live discharge. There was no documented evidence that the hospice medical director was consulted, reviewed clinical information, and agreed that the patient was no longer eligible for services and should be discharged. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the hospice medical director did not oversee the implementation of the entire nursing, social work, therapy, and counseling areas consistently to meet patient and family needs. The patient record contained no documented evidence of the hospice medical director's review of clinical information that was then used to narrate certification of the patient's terminal illness at the start of care. There was no documented evidence that the physician participated with the Interdisciplinary Group (IDG) to develop or update the patient's plan of care to ensure that patient and family needs were being met at the start of care and at least every 15 days up to the point of the patient's death. The Administrator was consulted by the DPCS to inquire if the physician had written proof of oversight activities of the medical component of the hospice's patient care program. The Administrator stated that she contacted both the former and current medical directors who had responsibility for the hospice's patient care program since the organization's initial deemed survey. The Administrator stated that neither hospice medical director had documented evidence of participation in or oversight of the hospice's patient care program including written certifications of terminal illness for Records 1, 2, 3, or 4.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement; Responses to medications, symptom management, treatments, and services; Outcome measure data elements per regulation; Physician certification and recertification of terminal illness as required; Any advance directives; Copies of inpatient discharge summary, as applicable; Physician orders. This CONDITION was not met as evidenced by clinical record review and interview. The agency failed to ensure that all records contained at a minimum initial and updated plans of care and updated comprehensive assessments [HSIM.3.I/L672]; that the medical director provided timely written and signed recertifications of the terminal illness [HCPC.6.I/L676]; that the clinical records contained physician orders [HSIM.3.I/L678] and that the patients' clinical records were safeguarded from alteration [HSIM.5.I/L680]. The cumulative effect of these deficiencies resulted in the hospice's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.104: Clinical Records. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice service from the agency.

It is required that each patient’s record includes, at a minimum the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, the organization did not ensure that records contained at a minimum initial and updated plans of care and updated comprehensive assessments. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient's clinical record did not include an initial plan of care or updated plans of care throughout the course of care and services from the start of care through live discharge. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed the clinical record did not include updated comprehensive assessments including no recertification assessment in benefit period 10 (4/26/2023-6/24/2023); and did not include an initial plan of care or updated plans of care throughout the course of care and services from the start of care through live discharge. Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient's clinical record did not include an initial plan of care or updated plans of care throughout the course of care and services from the start of care through live discharge. Clinical Record 4: The patient was admitted to hospice services on 9/15/2022. The patient died on 11/28/2022. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient's clinical record did not include an initial plan of care or updated plans of care throughout the course of care and services from the start of care up to the patient's death. During the electronic medical record review on 9/26/2023, the DPCS confirmed that Records 1, 2, 3, and 4 did not include initial and updated plans of care; and Record 2 did not include an updated comprehensive assessment in Benefit Period 10.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification 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 3 of 3 (100%) clinical records in which the patient received services in more than one benefit period, the organization did not ensure that the hospice medical director provided timely written and signed recertification of the terminal illness. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the hospice medical director wrote a recertification of the terminal illness 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 began for each of the patient's benefit periods (benefit periods 3-9). Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the hospice medical director wrote a recertification of the terminal illness 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 began for each of the patient's benefit periods (benefit periods 3-11). Clinical Record 3: The patient was admitted to hospice services on 7/5/2022. Services continued through benefit period 2 effective 10/3/2022-12/30/2022. The patient was live discharged on 12/30/2022 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that there was no documented evidence that the hospice medical director wrote a recertification of the terminal illness no later than two (2) calendar days after the first day of the second benefit period, and no more than fifteen (15) days before the second benefit period began. The Administrator stated that she contacted both the former and current medical directors who had responsibility for the hospice's patient care program since the organization's initial deemed survey. The Administrator stated that neither hospice medical director had documented evidence of timely written and signed recertifications of terminal illness for Records 1, 2, 3, or 4.

It is required that each patient’s record includes, at a minimum physician's orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed, the organization did not ensure that records contained, at a minimum, physician orders. Clinical Record 1: The patient was admitted to hospice services on 12/17/2021. Services continued through benefit period 9 effective 4/11/2023 until the patient was live discharged on 6/9/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that the patient record did not include physician orders. Clinical Record 2: The patient was admitted to hospice services on 9/5/2021. Services continued through benefit period 11 effective 6/25/2023 until the patient was live discharged on 6/29/2023 as determined to be no longer terminally ill with a life expectancy of 6 months or less. A joint clinical record review with the DPCS on 9/26/2023 revealed that include physician orders. During the electronic medical record review on 9/26/2023, the DPCS confirmed that Records 1 and 2 did not include any documented physicians' orders for any services or treatments.

It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use. The hospice addresses prevention of physical or electronic altering of the patient record. The hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed; it was revealed that the hospice did not safeguard the patient record from alteration in accordance with the HITECH Act. Clinical Record 4: Patient SOC 09/15/22 with a discharge date of 11/28/22. During clinical record review with Director of Patient Care Services (DPCS) on 9/26/23, it was revealed that clinical record 4 lacked required components including a plan of care with problems, goals and interventions. Subsequent review of clinical record number 4 on 9/27/23 to confirm findings revealed five care plan problems with the following dates and times. Problem 1, 09/27/2023, 09:17 PST. Problem 2, 09/27/2023 09:21 PST. Problem 3, 09/27/2023 09:25 PST. Problem 4, 09/27/2023, 09:27 PST. Problem 5, 09/27/2023 09:55 PST. During the exit conference on 9/28/2023, the Administrator confirmed that the Plan of Care problems, interventions, and goals presented for review on the afternoon of 9/27/2023 were documented in the patient's clinical record during the morning of 9/27/2023, the day after the electronic medical record was reviewed with the DPCS on 9/26/2023, and almost 10 months after the patient died on 11/28/2022.