Every finding on record at Passionate Hospice LLC

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) applicable clinical records of patients who elected hospice services after the date of the last site visit 2/29/2024, the hospice did not ensure the hospice RN implemented the interdisciplinary plan of care. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 1: The patient elected the hospice benefit on 3/14/2024. There was no documented initial hospice interdisciplinary plan of care until the first scheduled IDG meeting plan of care. A review of the electronic medical record (EMR) visit calendar identified scheduled hospice aide and nursing visits. Physician's orders were documented on 3/14/2024 for medications. The initial nursing assessment on 3/14/2024 documented the identified nursing care plan problems, goals, and interventions that did not get on the hospice interdisciplinary (IDG) plan of care until the first scheduled IDG meeting plan of care. The first interdisciplinary (IDG) hospice plan of care was established at the first IDG meeting on 3/21/2024 and did not include staff visit frequencies. The next IDG hospice plan of care was dated 4/4/2024 and did not include staff visit frequencies. Clinical Record 2: The patient elected the hospice benefit on 4/8/2024. There was no documented initial hospice interdisciplinary plan of care and/or physician's orders for nursing visit frequencies. The initial nursing assessment on 4/8/2024 documented the identified nursing care plan problems, goals, and interventions that did not get documented on a hospice interdisciplinary plan of care. No documented IDG plan of care since the first IDG meeting had occurred. A review of the electronic medical record (EMR) visit calendar identified scheduled nursing visits. A physician's order for medications was documented on 4/8/2024. Clinical Record 5: The patient elected the hospice benefit on 3/16/2024. There was no documented initial hospice interdisciplinary plan of care until the first scheduled IDG meeting plan of care on 3/25/2024. A review of the electronic medical record (EMR) visit calendar identified scheduled hospice aide, nursing, and spiritual counselor visits. Physician's orders were documented on 3/16/2024 for medications. The initial nursing assessment on 3/16/2024 documented the identified nursing care plan problems, goals, and interventions that did not get on the hospice interdisciplinary (IDG) plan of care until the first scheduled IDG meeting plan of care dated 3/25/2024. The first IDG hospice plan of care was established at the first IDG meeting on 3/25/2024 and included spiritual counselor visit frequency and did not include nursing and aide visit frequencies. The next IDG hospice plan of care dated 4/8/2024 included spiritual counselor visit frequency and did not include nursing and aide visit frequencies. During an interview on 4/12/2024, the VP of Compliance stated, "Before we implemented this new electronic medical record (EMR) format in January 2/2024, we used to do an initial plan of care on admission to the hospice which included the staff visits frequency orders", "We have calls out to the EMR company to assist us in locating the missing hospice plan of care to include staff visit frequency orders", "I can only pull up the first IDG plan of care at the first scheduled IDG meeting and I see the missing staff visit frequencies on the IDG meeting plans of care", and "The orders for the staff visit frequencies must be in the EMR since the staff visits are on the EMR calendar but I cannot see the hospice plan of care until the first IDG meeting" and "I have several calls out to the (EMR company) to be able to see the missing orders and initial plans of care which contain the visit frequencies". THIS IS A CONTINUED REQUIRED ACTION. During an interview on 4/12/2024, the VP of Compliance stated, "Before we implemented this new electronic medical record (EMR) format in January 2/2024, we used to do an initial plan of care on admission to the hospice which included the staff visits frequency orders", "We have calls out to the EMR company to assist us in locating the missing hospice plan of care to include staff visit frequency orders", "I can only pull up the first IDG plan of care at the first scheduled IDG meeting and I see the missing staff visit frequencies on the IDG meeting plans of care", and "The orders for the staff visit frequencies must be in the EMR since the staff visits are on the EMR calendar but I cannot see the hospice plan of care until the first IDG meeting" and "I have several calls out to the (EMR company) to be able to see the missing orders and initial plans of care which contain the visit frequencies".

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: 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 3 of 7 (43%) clinical records reviewed, the hospice did not ensure the plan of care and/or physician's orders contained a detailed statement of the scope and frequency of services for hospice staff visiting the patient. Clinical Record 1: The patient elected the hospice benefit on 3/14/2024. There were no documented nursing and aide visit frequencies on an order, a hospice plan of care, and/or an IDG plan of care. A review of the electronic medical record (EMR) visit calendar identified scheduled hospice aide and nursing visits. No interdisciplinary (IDG) hospice plan of care was established on admission on 3/14/2024 and there were no documented physician's orders to include staff visit frequencies. A physician's order for medications was documented on 3/14/2024. The first interdisciplinary (IDG) hospice plan of care was established at the first IDG meeting on 3/21/2024 and did not include staff visit frequencies. The next IDG hospice plan of care was dated 4/4/2024 and did not include staff visit frequencies. Clinical Record 2: The patient elected the hospice benefit on 4/8/2024. There were no documented nursing visit frequencies on a physician's order or a hospice plan of care. No IDG plan of care since the first IDG meeting had occurred. review of the electronic medical record (EMR) visit calendar identified scheduled nursing visits. A physician's order for medications was documented on 4/8/2024. Clinical Record 4: The patient elected the hospice benefit on 12/25/2023. For nursing and aide visit frequencies during the dates of service reviewed 3/1/2024 through 4/1/22024, there were no documented nursing and aide visit frequencies on an order, a hospice plan of care, and/or an IDG plan of care. A review of the electronic medical record (EMR) visit calendar identified scheduled hospice aide and nursing visits. During the dates of service reviewed, the IDG plans of care dated 3/11/2024, 3/25/2024, and 4/8/2024 did not include nursing and aide visit frequencies. During an interview on 4/12/2024, the VP of Compliance stated, "On these clinical records of patients that were on service in January 2024 when we implemented the new electronic medical record (EMR) system, we needed to re-entry all the information, orders, and plans of care into the new EMR system", and "I can only see the staff visit frequencies on the visit calendar in the EMR and I cannot see or open an order or a plan of care to see the staff visit frequencies.” During an interview on 4/12/2024, the VP of Compliance stated, "We have a new electronic medical record (EMR) format that we implemented in January 2024 and I cannot pull up the missing staff visit frequencies on a physician's order, a hospice plan of care or an IDG plan of care", "I can only see the staff visit frequencies on the electronic medical record visit calendar so the order must be in the system, but I cannot pull up or see a physician's order, a hospice plan of care, or an IDG plan of care that contains the missing staff visit frequencies", "I have several calls out to the (EMR company) to be able to see the missing orders and plans of care which contain the visit frequencies", and "Before we implemented this new EMR format, we used to do an initial plan of care that included staff visit frequencies". During an interview on 4/12/2024, the VP of Compliance stated, "We have a new electronic medical record (EMR) format that we implemented in January 2024 and I cannot pull up the missing staff visit frequencies on a physician's order, a hospice plan of care or an IDG plan of care", "I can only see the staff visit frequencies on the electronic medical record visit calendar so the order must be in the system, but I cannot pull up or see a physician's order, a hospice plan of care, or an IDG plan of care that contains the missing staff visit frequencies", "I have several calls out to the (EMR company) to be able to see the missing orders and plans of care which contain the visit frequencies", and "Before we implemented this new EMR format, we used to do an initial plan of care that included staff visit frequencies".

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) applicable clinical records of patients receiving hospice aide services at the time of review, the agency did not ensure the hospice registered nurse (RN) provided complete and patient-specific instructions to the hospice aide. THIS IS AN CONTINUED REQUIRED ACTION The agency policy Hospice Aide Services (Reference #14.22.1) effective 07/13/2022 included in part that "... The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide on the patient-specific care to be provided. The hospice aide's services are reviewed in the IDG (Interdisciplinary Group Meeting), and included in the patient's plan of care..." Clinical Record 1: The patient elected the hospice benefit on 3/14/2024. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of three times a week. A review of the clinical record revealed that the hospice aide plan of care dated 3/14/2024 did not include the assigned task of bathing the patient. The RN's supervisory visits dated 3/28/2024 and 4/8/2024 included, "Hospice aide responsibilities: bathing". Specific instructions to the aide for bathing the patient were not documented on the aide plan of care until the aide plan of care was updated on the date of review 4/11/2024. During an interview on 4/12/2024, the VP of Compliance stated, "We have a new electronic medical record (EMR) format that we implemented in January 2024 and I cannot pull up the missing staff visit frequencies on a physician's order, a hospice plan of care or an IDG plan of care", "I can only see the staff visit frequencies on the electronic medical record visit calendar so the order must be in the system, but I cannot pull up or see a physician's order, a hospice plan of care, or an IDG plan of care that contains the missing staff visit frequencies", "I have several calls out to the (EMR company) to be able to see the missing orders and plans of care which contain the visit frequencies", and "Before we implemented this new EMR format, we used to do an initial plan of care that included staff visit frequencies". During joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, "Yes, the aide plans of care are not specific to the tasks that the aides need to perform", "The RN is documenting aide responsibilities in the supervisory visits that do not match the tasks on the aide plan of care", "We assigned our aide scheduler to do aide plan of care audits and we knew from the audit findings that we still needed to work on the aide plans of care", "We have new nurses in the field and we now have the new QAPI Coordinator that training nurses in the field", and "Each morning during standup report, I am doing training with the nurses on what is expected in the aides' plan of care". THIS IS AN CONTINUED REQUIRED ACTION. During joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, "Yes, the aide plans of care are not specific to the tasks that the aides need to perform", "The RN is documenting aide responsibilities in the supervisory visits that do not match the tasks on the aide plan of care", "We assigned our aide scheduler to do aide plan of care audits and we knew from the audit findings that we still needed to work on the aide plans of care", "We have new nurses in the field and we now have the new QAPI Coordinator that training nurses in the field", and "Each morning during standup report, I am doing training with the nurses on what is expected in the aides' plan of care". The agency policy Hospice Aide Services (Reference #14.22.1) effective 07/13/2022 included in part that "... The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide on the patient-specific care to be provided. The hospice aide's services are reviewed in the IDG (Interdisciplinary Group Meeting), and included in the patient's plan of care..."

It is required that a hospice aide provides service ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) applicable clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide provided visits and/or tasks as ordered by the Interdisciplinary Group and included in the plan of care. THIS IS AN CONTINUED REQUIRED ACTION. The policy "Timely Submission of Patient Documentation", (Reference #11.05.1) effective 03/21/2021, included, in part, "The agency will ensure timely and proper submission of patient documentation, Clinical documentation will be complete and submitted within 24 hours from patient encounter...". The hospice's policy "Hospice Aide Supervision", (Reference #14.21.1) effective 07/13/2022, included, in part, "...The supervisory visits are documented in the patient's clinical record every two weeks and include notations whether the aide is following the patient's plan of care...". Clinical Record 1: The patient elected the hospice benefit on 3/14/2024. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of three times a week. A review of the clinical record revealed that the hospice aide plan of care dated 3/14/2024 included, in part, the assigned tasks of "Temperature" (T), "pulse" (P), "respirations" (R), "blood pressure" (BP), "pulse oximetry", and "weight". During the dates of service reviewed, the hospice aide visit notes dated 3/15/2024, 3/18/2024, 3/20/2024, 3/25/2024, 3/27/2024, and 3/29/2024 included a "checkmark" as "completed" for the assigned tasks of "Temperature" (T), "pulse" (P), "respirations" (R), "blood pressure" (BP), "pulse oximetry", and "weight". There were no TPR, BP, weight, or pulse oximetry results documented by the hospice aide in the clinical record. Additionally, a review of the clinical record revealed missing hospice aide visit notes to review after 3/29/2024. Clinical Record 4: The patient elected the hospice benefit on 12/25/2023. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of five times a week. A review of the clinical record revealed that the hospice aide plan of care dated 12/29/2023 included, in part, the assigned tasks of, "Barrier products (specify)", "range of motion (specify)", "fall precautions (specify)", and "Tasks: height and weight, special tasks, and No Tasks". The hospice aide's care plan was not specific and did not specify the barrier products, range of motion, fall precautions, special tasks, or instructions on what "no tasks" were to be performed by the aide. During the dates of service reviewed, the clinical record was missing one visit for 3/16/2024. The aide visit was scheduled for 3/15/2024 and moved per request to 3/16/2024. Additionally, there were two missed aide visits the week of 3/18/2024 (scheduled on the visit calendar for 3/18/2024 and 3/19/2024). There was no documented missed aide visit reports, orders, and/or hospice plans of care for the missed aide visits. Additionally, a clinical record review revealed missing hospice aide visit notes after 3/28/2024. Additionally, the hospice aide visit notes dated 3/20/2024, 3/21/2024 3/22/2024, 3/25/2024, 3/26/2024, 3/27/2024, 3/28/2024, and 4/2/2024 included a "checkmark" as "not completed" for the assigned tasks of "Barrier products", "specify)", "range of motion", "fall precautions", "height and weight", "special task" and the assigned "No Tasks". There was no documentation in the clinical record that the hospice aide communicated with the RN about why the aide's plan of care tasks was not completed. Clinical Record 6: The patient elected the hospice benefit on 3/22/2024. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of five times a week. A review of the clinical record revealed that the hospice aide plan of care dated 3/22/2024 included, in part, the assigned tasks of, "Temperature" (T), pulse" (P), "respirations" (R), "blood pressure" (BP), and "pulse oximetry". During the dates of service review, a clinical record review revealed four missing hospice aide visit notes for the weeks of 3/25/2024 and 4/1/2024. There was no documented missed aide visit reports, orders, and/or hospice plans of care for the missed aide visits. Additionally, the hospice aide visit note dated 4/8/2024 included a "checkmark" as "not completed" for the assigned tasks of "TPR, BP, and pulse oximetry" and no TPR, BP, and/or pulse oximetry was documented by the hospice aide. There was no documentation in the clinical record that the hospice aide communicated with the RN about why the aide's plan of care tasks was not completed. Additionally, the hospice aide visit notes dated 3/23/2024, 3/25/2024, and 4/5/2024 included a "checkmark" as "completed" for the assigned tasks of "TPR, BP, and pulse oximetry" and no TPR, BP, and/or pulse oximetry results were documented by the hospice aide. During a joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, "Yes, the aides are not documenting all the tasks as assigned on the aide plan care and there is no documentation that the aides communicated with the RN as to why the assigned tasks were not performed", "The missing aide visit notes are not documented in the clinical record", "I do not see the aide missed visit reports, orders and/or a plan of care for the missing aide visit notes", "We assigned our aide scheduler to do aide visit note audits and we know from our audit results that we still needed to work on the aide visit notes", "We have a new electronic medical record format since January 2024 and I cannot pull up the missing aide visit frequencies on an order, hospice plan of care or an IDG plan of care, I can only see the aide visit frequencies on the electronic medical record visit calendar", "We have new nurses in the field and we now have the new QAPI Coordinator for the past 2 weeks that is training staff in the field", and "Each morning during standup report, I am doing training with the nurses and aides on what is expected in the aide visit notes". THIS IS AN CONTINUED REQUIRED ACTION. During a joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, "Yes, the aides are not documenting all the tasks as assigned on the aide plan care and there is no documentation that the aides communicated with the RN as to why the assigned tasks were not performed", "The missing aide visit notes are not documented in the clinical record", "I do not see the aide missed visit reports, orders and/or a plan of care for the missing aide visit notes", "We assigned our aide scheduler to do aide visit note audits and we know from our audit results that we still needed to work on the aide visit notes", "We have a new electronic medical record format since January 2024 and I cannot pull up the missing aide visit frequencies on an order, hospice plan of care or an IDG plan of care, I can only see the aide visit frequencies on the electronic medical record visit calendar", "We have new nurses in the field and we now have the new QAPI Coordinator for the past 2 weeks that is training staff in the field", and "Each morning during standup report, I am doing training with the nurses and aides on what is expected in the aide visit notes". The policy "Timely Submission of Patient Documentation", (Reference #11.05.1) effective 03/21/2021, included, in part, "The agency will ensure timely and proper submission of patient documentation, Clinical documentation will be complete and submitted within 24 hours from patient encounter...". The hospice's policy "Hospice Aide Supervision", (Reference #14.21.1) effective 07/13/2022, included, in part, "...The supervisory visits are documented in the patient's clinical record every two weeks and include notations whether the aide is following the patient's plan of care...".

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) applicable clinical records of patients receiving hospice aide service, the hospice did not ensure the RN documented supervisory visits at least every 14 days and/or the RN documented the assessment of the quality of care and services provided by the hospice aide and that services meet the patient's need. THIS IS AN CONTINUED REQUIRED ACTION. The agency policy "Hospice Aide Supervision", (#14.21.1) effective 07/13/2022, included, in part, "... A registered nurse makes an on-site visit to the patient's home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient's need...The supervisory visits are documented in the patient's clinical record every 2 weeks...". The hospice's policy "Timely Submission of Patient Documentation", (Reference #11.05.1) effective 03/12/2021, included, in part "The agency will ensure the timely and proper submission of patient documentation...Clinical documentation will be complete and submitted within 24 hours from the patient encounter...". Clinical Record 4: The patient elected the hospice benefit on 12/25/2023. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of five times a week. The hospice aide plan of care dated 12/29/2023 included the assigned tasks of "barrier products (specify)", "ROM (specify)", "fall precautions (specify)", and "TASKS: height, weight, special tasks, NO tasks". The hospice aide plan of care did not provide specific instructions to the aide for the barrier product to use, the specified ROM (range of motion), fall precautions, and special tasks to provide, and did not specify the "no tasks" to not perform. During the dates of service reviewed, the clinical record was missing one visit for 3/16/2024. The aide visit was scheduled for 3/15/2024 and moved per request to 3/16/2024. Additionally, there were two missed aide visits the week of 3/18/2024 (scheduled on the visit calendar for 3/18/2024 and 3/19/2024). There were no documented missed aide visit reports, orders, and/or hospice plans of care for the missed aide visits. A clinical record review also revealed missing hospice aide visit notes after 3/28/2024. Additionally, the hospice aide visit notes dated 3/20/2024, 3/21/2024 3/22/2024, 3/25/2024, 3/26/2024, 3/27/2024, 3/28/2024, and 4/2/2024 included a "checkmark" as "not completed" for the assigned tasks of "Barrier products", "specify)", "range of motion", "fall precautions", "height and weight", "special task" and the assigned "No Tasks". There was no documentation in the clinical record that the hospice aide communicated with the RN about why the aide's plan of care tasks were not completed. During the dates of service reviewed, the RN documented the hospice aide supervisory visits on 3/16/2024 and 3/29/2024. A review of the RN's supervisory visit documentation for the hospice aide dated 3/16/2024 included, "Hospice aide responsibilities: TPR", which was not included in the aide plan of care. The RN's supervisory visit for the aide dated 3/29/2024 included, "Hospice aide responsibilities: TPR and BP", which was not included in the aide plan of care. The RN's supervisory visits documentation included, "following the aide plan of care" and "no changes to the aide plan of care". There was no RN documentation as to why the tasks assigned on the aide plan of care were not completed by the aide and why the fall precautions, ROM, height, weight, special tasks, and NO tasks" were not documented as performed by the hospice aide. Clinical Record 6: The patient elected the hospice benefit on 3/22/2024 and was transferred to another hospice on 4/9/2024. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of five times a week. A review of the clinical record revealed that the hospice aide plan of care dated 3/22/2024 included, in part, the assigned tasks of, "Temperature" (T), pulse" (P), "respirations" (R), "blood pressure" (BP), and "pulse oximetry". The hospice aide visit note dated 4/8/2024 included a "checkmark" as "not completed" for the assigned tasks of "TPR, BP, and pulse oximetry" and no TPR, BP, and/or pulse oximetry was documented by the hospice aide. The hospice aide visit notes dated 3/25/2024 and 4/5/2024 included a "checkmark" as "completed" for the assigned tasks of "TPR, BP, and pulse oximetry", and no TPR, BP, and/or pulse oximetry results were documented by the hospice aide. There was no documentation in the clinical record that the hospice aide communicated with the RN as to why the aide's plan of care tasks were not completed and documented. During the dates of service review, a clinical record review revealed four missing hospice aide visit notes for the weeks of 3/25/2024 and 4/1/2024. The hospice aide's first visit was dated 3/23/2024. There were no documented RN supervisory visits for the hospice aide from 3/23/2024 through the date of discharge 4/9/2024. During a joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, "Yes, I do not see the missing RN supervisory visits for the hospice aide and I opened up each RN visit note to try and find the missing aide supervisory notes", "I see the RN is documenting aide responsibilities in the supervisory visit note that did not get on the aide plan of care", and "Yes, the RN is documenting in the supervisory visit note that the aide plan of care is being followed when the tasks assigned on the aide plan of care are not completed". THIS IS AN CONTINUED REQUIRED ACTION. During a joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, "Yes, I do not see the missing RN supervisory visits for the hospice aide and I opened up each RN visit note to try and find the missing aide supervisory notes", "I see the RN is documenting aide responsibilities in the supervisory visit note that did not get on the aide plan of care", and "Yes, the RN is documenting in the supervisory visit note that the aide plan of care is being followed when the tasks assigned on the aide plan of care are not completed". The agency policy "Hospice Aide Supervision", (#14.21.1) effective 07/13/2022, included, in part, "... A registered nurse makes an on-site visit to the patient's home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient's need...The supervisory visits are documented in the patient's clinical record every 2 weeks...". The hospice's policy "Timely Submission of Patient Documentation", (Reference #11.05.1) effective 03/12/2021, included, in part "The agency will ensure the timely and proper submission of patient documentation...Clinical documentation will be complete and submitted within 24 hours from the patient encounter...".

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) applicable clinical records reviewed in which there was a live discharge from the hospice agency revealed the agency did not ensure that the patient's discharge summary was forwarded to the Medicare-certified facility upon discharge. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 7: The patient elected hospice on 11/3/2023 and was live discharged to a non-contracted Medicare hospital on 4/9/2024. A review of the clinical record identified a discharge summary which was dated 4/9/2024. There was no documented evidence that the discharge summary was forwarded to the receiving facility. During an interview on 4/12/2024, the VP of Compliance stated, "I do not see a note or documentation in the clinical record that the discharge summary was forwarded to the facility" and "I checked with the person who forwards the documents to the facilities and confirmed that a copy of the discharge summary was not sent to the facility. THIS IS A CONTINUED REQUIRED ACTION.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) applicable live discharged patients, the hospice did not ensure the discharge summary contained all the required elements. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 7: The patient elected hospice on 11/3/2023 and was live discharged to a non-contracted Medicare hospital on 4/9/2024. A review of the clinical record identified a discharge summary which was dated 4/9/2024. There was no documented evidence that the discharge summary also included the required elements of the hospice plan of care and the latest physician's orders. During an interview on 4/12/2024, the VP of Compliance stated, "The discharge summary format does not include the hospice plan of care and physician's orders, "I checked with the person who usually forwards the documents to the facilities and confirmed that a copy of the discharge summary, the hospice plan of care and orders were not sent to the facility", and "On the other patient's chart we reviewed, we found copies of the hospice plan of care and orders that were sent along with the discharge summary to another facility". THIS IS A CONTINUED REQUIRED ACTION.

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 IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice failed to ensure that the medication profile included all of the patient's current prescription and over the counter (OTC) drugs [HCPC. 15. I/L530]; and Failed to ensure that the patient's updated comprehensive assessment was completed by all members of the Interdisciplinary Group and included documentation of the patient's response to care and/or progress toward identified goals{HCPC.17. I/L533}; Failed to ensure that the Registered Nurse ensured the implementation and coordination of the patient's plan of care and provided continuous assessment of the patient's and family's needs {HCPC.19. I/L540}; and Failed to ensure that every member of the Interdisciplinary Group completed the Initial Assessments within five days of the patient's election of hospice care {HCPC.9. I/L523}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.54: Initial and comprehensive assessment of the patient. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

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 3 of 19 (16%) clinical records reviewed revealed the agency did not ensure that every member of the Interdisciplinary Group completed the Initial Assessments within five days of the patient's election of hospice care. Comprehensive Assessment of Patient (Reference #14.16.1) effective date of 07/13/2022, "...The hospice IDG (Interdisciplinary Group) conducts and documents a patient-specific comprehensive assessment that identifies the patient's need for hospice care, including medical, nursing, psychosocial, emotional, and spiritual care...The comprehensive assessment is competed by the designated members of the IDG ... no later than five calendar days after the patient elects the hospice benefit...Each member of the IDG provides input into the comprehensive assessment within the scope of his/her practice and in accordance with the needs and desires of the patient..." Clinical Record 1: The patient elected the hospice benefit on 01/20/2024. The Initial Chaplain Assessment was not documented until 01/27/2024 - 7 days after admission. There was nothing noted in the Chaplain's assessment documentation as to why the visit was postponed. There was no missed visit documented and nothing noted in the Interdisciplinary Group Meeting 01/26/2024 regarding the delay. Clinical Record 3: The patient elected the hospice benefit on 01/09/2023. The first Chaplain visit was not documented until 01/30/2023. The noted documented 01/30/2023 included no reason the Initial Assessment was postponed outside the five-day regulation. There was no missed visit documented. The Interdisciplinary Group Meetings documented 01/23/23 and 02/06/2023 included no documentation for the delay in the initial Chaplain visit. Clinical Record 7: The patient elected the hospice benefit on 12/18/2022. The Initial Chaplain Assessment was not documented until 9 days after admission on 12/27/2022. There was no communication note, no missed visit, and no documentation in the Interdisciplinary Group Meetings 12/27/2022 or 01/09/2023 regarding the delay. During an interview with the Director of Nursing (DON) on 02/29/2024, it was confirmed there was no documented reason noted for the delay of the initial assessment visit outside the five-day regulatory window.

It is required that the medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. 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, document review and interview. In 13 of 19 (68%) clinical records reviewed revealed that the agency did not ensure that the patient's medication profile review was documented at least every fifteen days. Agency policy: Hospice Medication Profile (Reference #14.14.1) effective 07/13/2022 read in part that "A patient-specific medication profile is maintained for each patient and reviewed, at minimum, every 15 days...The patient's medication profile must be reviewed by the IDG (Interdisciplinary Group) whenever there is a significant change and, at a minimum, every fifteen days... The patient's medication profile review includes, but is not limited to determining accuracy and completeness of the profile, monitoring medication effectiveness, actual or potential medication-related effects and untoward interactions..." Hospice Medication Management (Reference #14.13.1), effective 07/13/2022, included in part that "...A Medication Profile is maintained for every patient and includes a listing of the current medication orders for each patient ... Clinical Record 3: The patient elected the hospice benefit on 01/09/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/17/2024 and 01/18/2024 included no medications listed or documented medication review. There was not another IDG meeting documented until 02/12/2024. There was no documented evidence of a medication review in the clinical record. Clinical Record 4: The patient elected the hospice benefit on 02/12/2023. As of 02/28/2024, there was a thirty-four-day gap between documented Interdisciplinary Group Meetings (IDG) from 12/11/2023 to 01/18/2024. There was no medication review documented during this time period. The Interdisciplinary Group Meetings (IDG) documentation on 01/18/2024 and 02/01/2024 included no medications listed and no documented medication review. During this site visitor's observation on home visit with the registered nurse (Personnel Record 5) on 02/28/2024, the patient's son and primary caregiver brought the patient's medications to the patient's room for the RN to review. These medications included Quetiapine 50mg by mouth twice a day and what the son reported to be Hydrocodone/Acetaminophen. The Hydrocodone was in a bottle with a label completely faded without the patient's name visible, the name of the medication, or the directions and frequency of use. There was no medication list in the patient's home. When questioned, the RN responded she would have to print one but that I could look at the chart on her iPad. Upon record review, the patient's medication list had documented both the Quetiapine 50mg by mouth twice daily and the Hydrocodone/Acetaminophen 5/325mg: one by mouth every four hours as needed for pain listed as discontinued. The nurse verified with the son that the patient was taking the Hydrocodone. There was no documented evidence of a medication review in the clinical record. Clinical Record 5: The patient elected the hospice benefit on 01/22/2023. A gap in documented Interdisciplinary Group Meetings (IDG) from 12/11/2023 to 01/17/2024 in which no medication review was documented. The Interdisciplinary Group Meetings (IDG) documentation on 01/17/2024, 01/29/2024, and 02/12/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, 01/29/2024, and 02/12/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 7: The patient elected the hospice benefit on 12/18/2022. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024 and 01/17/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 8: The patient elected the hospice benefit on 01/12/2024. The Interdisciplinary Group Meetings (IDG) documentation on 01/17/2024 and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 9: The patient elected the hospice benefit on 12/23/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 11: The patient elected the hospice benefit on 09/28/2023. The Interdisciplinary Group Meetings (IDG) held on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 12: The patient elected the hospice benefit on 04/20/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 13: The patient elected the hospice benefit on 04/22/2022. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 14: The patient elected the hospice benefit on 11/03/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022 and revoked the hospice benefit on 01/26/2024. As of 02/28/2024, there was a thirty-seven-day gap between documented Interdisciplinary Group Meetings (IDG) from 12/11/2023 to 01/17/2024. No Medication review was documented during this time period. The Interdisciplinary Group Meetings (IDG) documentation on 01/17/2024 included no medications listed and no documented medication review. During interviews with the Director of Nursing and the Administrator on 02/27/2024, 02/28/2024, and 02/29/2024, there was ongoing discussion of the difficulties the hospice experienced when switching from one electronic medical record (EMR) to another as of 01/01/2024. In addition to the change in EMRs, there was a change in the Director of Nursing staff. I questioned if there were any backup paper Interdisciplinary Meeting minutes or documentation related to reviewed patients, updates to care plans, medication reviews, signatures, etc. There was mentioned a signature sheet from the Medical Director, but no documentation was produced by the end of the site visit.

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 but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review and interview. In 14 of 19 (74%) clinical records reviewed revealed the agency did not ensure that the patient's updated comprehensive assessment was completed by all members of the Interdisciplinary Group and included documentation of the patient's response to care and/or progress toward identified goals. Document 1: Hospice Updates (Reference #14.20.1) effective 07/13/2022 "The hospice's IDG updates the comprehensive assessment and reassesses the patient's response to care on a regular basis. A patient's progress toward desired outcomes and response to care is reassessed as often as required by the patient's condition but no less frequently than every 15 days. Information from the updated comprehensive assessment is reviewed by the IDG at care planning meetings and is used to revise the patient's plan of care as needed. Documentation of the IDG's care planning meeting reflects the ongoing reassessment of the patent/family's status and needs. Hospice Coordination of Services (Reference #14.7.1) effective 03/12/2021 "...The IDG meets regularly to provide care planning for the hospice's patients/caregivers....All members of the IDG participate in care planning and document problems, interventions, goals, observations, and outcomes based on the assessed and reassessed needs of the patient/family..." Comprehensive Assessment of Patient (Reference #14.16.1) effective 07/13/2022 "...Each member of the IDG provides input into the comprehensive assessment within the scope of his/her practice and in accordance with the needs and desires of the patient..." Comprehensive Assessment - Patient Outcome Measure (Reference #14.19.1) effective 07/13/2022 "...The data collected from the patient's comprehensive assessment is used to provide individualized care planning, appropriate interventions and for the coordination of services for each patient..." Clinical Record 2: The patient elected the hospice benefit on 03/23/2022. An Interdisciplinary Group Meeting (IDG) was held on 12/07/2024. There was a forty-five-day gap between the Interdisciplinary Group Meeting (IDG) documented on 12/07/2023 to the next IDG on 01/17/2024. There was no documented evidence on the IDG note dated 01/17/2024 that included notes or updates from the team, no progress toward goals documented, no medications listed, or medication review documented. It was only electronically signed (e-signed) by the RN and the LVN. There were no e-signatures by the Medical Director, Social Worker, or the Chaplain. Clinical Record 3: The patient elected the hospice benefit on 01/09/2023. There was a twenty-seven-day gap in IDG documentation 12/21/2023 to 01/17/2024. Then, there was a twenty-five-day gap in documented IDG meetings from 01/18/2024 to 02/12/2024. There was no documented evidence on the IDG not dated 01/17/2024 that included notes or updates from the team, no progress toward goals documented, no medications listed, or medication review documented and no electronic signatures from the Medical Director, RN, Social Worker, or the Chaplain. The IDG documented on 01/18/2024 included notes from the Chaplain, Social Worker and Volunteer Coordinator documenting the patient declined all those services. There were no medications listed and no medication review documented. There were no electronic signatures on the document from the team. The IDG documentation on 02/12/2024 included only the Social Worker and the LVN electronic signatures. Clinical Record 4: The patient elected the hospice benefit on 02/12/2023. A thirty-four-day gap in Interdisciplinary Group Meetings was documented from 12/11/2023 to 01/18/2023. The IDG documented on 01/18/2024 included no team notes or updates except for the Volunteer Coordinator and the Social Worker, no progress toward goals documented, no medications listed or reviewed, and no electronic signatures from the Social Worker or Chaplain. The IDG documentation 02/01/2024 included no medications listed or reviewed and no electronic signatures from the Social Worker and Chaplain. Clinical Record 5: The patient elected the hospice benefit on 01/22/2023. A thirty-three-day gap in Interdisciplinary Group Meetings was documented from 12/11/2023 to 01/17/2023. The IDG documentation on 01/17/2024 included no medications listed or reviewed and no electronic signatures from the Social Worker or Chaplain. The IDG documentation on 01/29/2024 included no notes or updates from the team, medications listed or reviewed, and the only electronic signature was from the Social Worker. The IDG documentation on 02/12/2024 included only electronic signatures from the Social Worker and the LVN. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. Th IDG documentation on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed, or medication review documented. It was only electronically signed (e-signed) by the Social Worker. There were no e-signatures by the Medical Director, Nurse, or the Chaplain. The IDG documentation 01/17/2024 included notes from the Volunteer Coordinator's initial notes. There was no documentation from the Nurse, Social Worker, or Chaplain or progress toward goals were documented. There were no e-signatures by the Medical Director, Nurse, Social Worker, or the Chaplain. The IDG note on 01/29/2024 lacked evidence of progress toward goals, medications, medication review and no updated information except for the nurse. There was no electronic signatures Medical Director, Nurse, Social Worker, or Chaplain. The IDG noted dated lacked a medication review and electronic signatures of the Medical Director, Nurse, Social Worker, or Chaplain. Clinical Record 7: The patient elected the hospice benefit on 12/18/2022. The IDG dated 01/05/2024 did not include any updated information from the team, no progress toward goals documented, no medications listed, or medication review documented. There were no e-signatures by the Medical Director, Nurse, Social Worker, or the Chaplain. The IDG dated 01/17/2024 included only notes from the Volunteer Coordinator and did not include any updated information from the team, no progress toward goals documented, no medications listed, or medication review documented. The only e-signature was the RN. The IDG dated 01/29/2024 included notes and updates from the Volunteer Coordinator and RN only. The only e-signature was by the RN. The Interdisciplinary Group Meeting (IDG) documented on 02/12/2024 included no electronic signatures of the Medical Director, Nurse, Social Worker, or Chaplain. Clinical Record 8: The patient elected the hospice benefit on 01/12/2024. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no note or update from the nurse. No Medications were listed, and no medication review was documented. The documented e-signature of the Social Worker was missing. The Interdisciplinary Group Meeting (IDG) held on 01/29/2024 included notes and updates from the Social Worker, and Volunteer Coordinator only. There were no updates from the other team member or progress toward goals documented, no medications listed or reviewed. The Social Worker did not electronically sign the document. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 9: The patient elected the hospice benefit on 12/23/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed, no core team electronic signatures. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no notes or updates from the team except the Volunteer Coordinator, no progress toward goals documented, no medications listed or reviewed, and no core team electronic signatures. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no notes or updates from the team except for the Social Worker, no progress toward goals documented, no medications listed or reviewed, and no core team electronic signatures. The Interdisciplinary Group Meeting (IDG) documented on 02/12/2024 included no notes or progress toward goals documented, no medications listed or reviewed, only electronic signatures from the Social Worker and Hospice Aide. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 10: The patient elected the hospice benefit on 01/18/2024. The Interdisciplinary Group Meeting (IDG) documented on 01/18/2024 included no medications listed and only electronically signed by the Chaplain and Nurse. The Interdisciplinary Group Meeting (IDG) documented on 02/01/2024 included no medications listed or reviewed and only electronically signed by the Nurse, Chaplain, and Nurse. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 11: The patient elected the hospice benefit on 09/28/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and only electronically signed by the RN. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no notes or updates from the team except the Volunteer Coordinator, no progress toward goals documented, no medications listed or reviewed, and only electronically signed by the RN. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no medications listed and was missing the Medical Director and Chaplain's electronic signatures. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 12: The patient elected the hospice benefit on 04/20/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and no electronic signatures. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included notes from the Nurse and the Volunteer Coordinator only, no notes or updates from the Social Worker or Chaplain, no progress toward goals documented, no medications listed or reviewed, and only electronically signed by the RN. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no team notes or updates, no progress toward goals documented, no medications listed or reviewed, and no electronic signatures. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 13: The patient elected the hospice benefit on 04/22/2022. There was a sixteen-day gap between the Interdisciplinary Group Meeting (IDG) documented on 11/21/23 to the next documented IDG on 12/07/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and only electronic signatures from the RN and LVN. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no notes or updates from the team except the Volunteer Coordinator, and the nurse no progress toward goals documented, no medications listed or reviewed, only electronically signed by the RN and the LVN. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and only electronic signatures by the RN and LVN. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 14: The patient elected the hospice benefit on 11/03/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and only the electronic signatures of the RN and Social Worker. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no notes or updates from the team. The notes documented were copied from the IDG notes from 01/05/2024. No progress toward goals was documented, no medications were listed or reviewed, and only the Social Worker's electronic signature was documented. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no notes or updates from the team. The notes documented were copied from the IDG on 01/05/2024. No progress toward goals documented, no medications listed or reviewed, and only the Social Worker's electronic signature. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022 and revoked the hospice benefit on 01/26/2024. A thirty-seven-day gap between Interdisciplinary Group Meetings (IDG) was documented from 12/11/2023 to 01/17/2024. The IDG Meeting documented on 01/17/2024 included a note from the Volunteer Coordinator and a note from the Nurse in which it was noted that the patient revoked the hospice benefit, which did not occur until 01/26/2024. There were no medications listed or reviewed and no electronic signatures. During interviews with the Director of Nursing and the Administrator on 02/27/2024, 02/28/2024, and 02/29/2024, there was ongoing discussion of the difficulties the hospice experienced when switching from one electronic medical record (EMR) to another as of 01/01/2024. In addition to the change in EMRs, there was a change in the Director of Nursing staff. I questioned if there were any backup paper Interdisciplinary Meeting minutes or documentation related to reviewed patients, updates to care plans, medication reviews, signatures, etc. The Administrator said there was a signature sheet from the Medical Director, but no documentation was produced by the end of the site visit.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed revealed the agency did not ensure that the Registered Nurse ensured the implementation and coordination of the patient's plan of care and provided continuous assessment of the patient's and family's needs. Agency policy Timely Submission of Patient Documentation (Reference #11.05.1) effective 03/12/2021 included in part that "The Agency will ensue the timely and proper submission of patient documentation ...Clinical documentation will be complete and submitted within 24 hours from patient encounter..." Clinical Record 3: The patient elected the hospice benefit on 01/09/2023 with the diagnosis of Liver Failure. There was an order documented on 01/01/2024 for RN visits every fourteen days. There was a sixteen-day gap in documented RN visits from 01/03/2024 to 01/19/2024. On 01/03/2024 the RN documented that the patient had 3+ non-pitting edema to the left lower extremity red scaly areas. The patient reported intermittent cramping to fingers and upper thighs. The patient walked with a shuffle and was a fall hazard. The patient reported pain in the left lower leg that is chronically swollen. The LVN documented on 01/23/2024 that the patient complained of pain to the left lower extremity and took Tramadol for the pain. The nurse reviewed medications with the patient and caregiver and instructed the patient to adhere to the pain medication regimen. Clinical Record 4: The patient elected the hospice benefit on 02/12/2024 with the diagnosis of Prostate Cancer. On 02/28/2024 review of the clinical recorded revealed there was not a Plan of Care in the EMR. Under the Assignments for the patient, there was a documented RN frequency of once a week visits. As of 02/28/2024, no RN visit was documented the week of 01/28/2024, and no missed visit was documented. On 01/18/2024, the RN documented that the nurse provided education of the disease process related to possible weight loss, nutrition, and hydration and that ongoing teaching needs will be assessed at each nursing visit. The nurse documented a review of the patient's Hydrocodone and Quetiapine. On 01/25/2024, the RN noted that the patient used oxygen as needed and had an oxygen saturation of 95%. The caregiver reported that the patient's appetite declined and only ate 10-20% of child-sized meals. The patient had an unsteady gait and used a walker on standby assist and the nurse provided education on fall prevention. The patient appeared to have anxiety during the nurses’ assessment, and the nurse educated the caregiver on the use of Lorazepam 1mg as needed. Then, on 02/07/2024, the nurse documented that the patient denied pain but did have occasional pain to his right knee that was managed with Hydrocodone. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023 with the diagnosis of Heart Failure. A Physicians Order on 01/01/2024 documented RN visits twice a week. The week of 01/01/2024 there was only one RN. The week of 01/07/2024, the patient was seen by the LVN, not the RN; the week of 01/14/2024 there was one RN visit documented. A Physician's Order dated 01/20/2024 decreased the frequency of RN visits from twice to once a week. The week of 01/21/2024 there were no nursing visits documented. The last nursing visit documented was an RN visit on 01/29/2024. The RN documented in part during the RN visit on 01/02/2024 was “…wounds to right lower leg and left heel, pt has no open wounds to bil buttocks pt has redness to bil buttocks…PCG is using moisture barrier/triad paste to reduce redness and protect skin from incontinent bowel episodes…. .” Then on 01/15/2024 the RN documented the patient had “… wounds to right lower leg, and left heel, pt has open wounds to bil buttocks and redness to bil buttocks, wound care performed as ordered by physician, tol well. Pt has skin breakdown to bil buttocks and to right leg… Pt resides Son and DIL’s home with son and DIL who provide care…” There was no documented evidence of teaching to the family on wounds. There were scanned Progress Notes, wound assessments, and dressing changes for 01/12/2024, 02/12/2024, and 02/23/2024 performed by the Wound RN and NP and signed by the wound care Medical Director. On 01/12/2024, the progress note included the following: Right medial stage 3 pressure ulcer (3.92 x 5.22 x 0.11) - Cleanse the wound with cleaner and pat dry with gauze. Apply skin prep to the peri-wound. Apply topical antibiotic spray and Therahoney to the wound bed, followed by alginate. Cover with foam and silicone-bordered dressing three times a week and as needed when soiled or loose. Wound Pros clinician to change once weekly and the agency/caregiver twice a week and available as needed for soiled or loose dressing changes. Right lateral lower leg venous stasis ulcer (8.69 x 18.67 x 0.11) - Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by collagen and oil emulsion gauze. Cover with absorbent pad dressing and wrap with rolled gauze three times a week and as needed for soiled or loose dressing. Secure the dressing with tape as needed. Wound Clinic to change once weekly and the agency/caregiver twice weekly and be available to change soiled or loose dressing. Clinical Record 10: The patient elected the hospice benefit on 01/18/2024 with the diagnosis of Colon Cancer. There was no plan of care documented for the patient as of 02/27/2024. The assignments effective 01/21/2024 documented the frequency of team visits, which included for the skilled nurse to visit the patient twice a week. RN visits were documented on 01/18/2024, 01/19/2024, 01/24/2024, and 01/30/2024. There was no nurse visit documented after 01/30/2024. It was observation during Home Visit 4 with the Social Worker (Personnel Record 6) on 02/28/2024), that the patient and spouse had a significant language barrier, had teaching needs about what medications the patient was to take and for what those medications were to be used, overall did not appear to have a good understanding of the disease progression. Clinical Record 11: The patient elected the hospice benefit on 09/28/2023 with the diagnosis of Heart Failure. A physician order dated 01/06/2024 stated the RN to make weekly visits and the LVN to make weekly visits. There was a fifteen-day gap between RN visits from 01/10/24 to 01/25/24. At the time of clinical record review, no RN visits were documented after 01/25/2024, which is a thirty-two-day gap from 01/25/2024 to 02/25/2024. Clinical Record 14: The patient elected the hospice benefit on 11/3/2023 with the diagnosis of Cerebrovascular Disease. A Physician Order was documented on 01/06/2024 for the RN to make weekly visits and the LVN to make weekly visits. There was a nineteen-day gap between nursing visits from 01/13/2024 to 02/01/2024 and a twenty-five-day gap between RN visits from 01/13/2024 to 02/07/2024. The patient's medication list included Eliquis to prevent blood clots, Tramadol for pain, and Levetiracetam for seizures. The missing nurse visit documentation was discussed during an interview with the Director of Nursing (DON) on 02/28/2024 and 02/29/2024. The DON stated there was difficulty transitioning from the previous electronic medical record (EMR) to the new EMR with order entry and access to the clinician's portable devices. A couple of nurses were contacted by phone by the DON and the nurses indicated that the visits had been performed but not documented. I reviewed the agency's policy on timely patient documentation, which states that clinical documentation will be submitted within twenty-four hours.

It is required that each patient’s individualized written plan of care Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that there were identified problems with planned interventions to address the patient's wounds and the coordination with the wound care specialists. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. Documented in part during the RN visit on 01/02/2024 was “…wounds to right lower leg and left heel, pt has no open wounds to bil buttocks pt has redness to bil buttocks…PCG is using moisture barrier/triad paste to reduce redness and protect skin from incontinent bowel episodes…. .” On 01/15/2024, the RN noted that the patient “… wounds to right lower leg, and left heel, pt has open wounds to bil buttocks and redness to bil buttocks, wound care performed as ordered by physician, tol well. Pt has skin breakdown to bil buttocks and to right leg… Pt resides Son and DIL’s home with son and DIL who provide care…” There was no documentation of teaching to family on wounds. Progress Notes, wound assessments, and dressing changes for 01/12/2024, 02/12/2024, and 02/23/2024 were from an outside wound specialist. The Wound RN and NP documented the assessments and dressing changes and signed them by the wound care Medical Director. On 01/12/2024, the progress note included the following: Right medial stage 3 pressure ulcer (3.92 x 5.22 x 0.11) - Cleanse the wound with cleaner and pat dry with gauze. Apply skin prep to the peri-wound. Apply topical antibiotic spray and Therahoney to the wound bed, followed by alginate. Cover with foam and silicone-bordered dressing three times a week and as needed when soiled or loose. Wound Pros clinician to change once weekly and the agency/caregiver twice a week and available as needed for soiled or loose dressing changes. Right lateral lower leg venous stasis ulcer (8.69 x 18.67 x 0.11) - Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by collagen and oil emulsion gauze. Cover with absorbent pad dressing and wrap with rolled gauze three times a week and as needed for soiled or loose dressing. Secure the dressing with tape as needed. Wound Clinic clinician to change once weekly and the agency/caregiver twice weekly and be available to change soiled or loose dressing. There was no identified problem for the patient's wounds and no planned interventions for hospice wound assessments, how often the hospice was providing dressing changes, or if the hospice was also teaching the caregivers how to care for the wound per the wound care orders provided by the specialists. It was confirmed during an interview with the Director of Nursing (DON) on 02/29/2024 that the wound specialists continued seeing the patient to address the patient's wounds. During the joint clinical record review, it was also confirmed that the hospice clinical record did not include any identified interventions to address the wound care frequency and responsibility between wound care specialist visits.

It is required that the agency provide 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. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed revealed that the agency did not ensure that spiritual counseling was provided per the plan of care. Clinical Record 2: The patient elected the hospice benefit on 03/23/2022. A Physician's Order was dated 01/15/2024 for once-a-month Chaplain visits. There were no documented Chaplain visit for January 2024. A note was entered as a missed visit by the Chaplain on 02/17/2024 that read, "Patient load doubled in the middle of the month. Unable to visit them all." There was no documentation of any attempts to have the visit covered by another Chaplain or the patient/family declined the Chaplain visit ordered by the Interdisciplinary Group. Clinical Record 5: The patient elected the hospice benefit on 01/22/2023, A Plan of Care Order dated 12/11/2023 included a once-a-month Chaplain visit frequency. Then, a Physician's Order dated 01/01/2024 documented a one-time Chaplain visit to determine frequency. Again, under Assignments effective 01/22/2024 (per Physician Order dated 01/22/2024) documented a Chaplain frequency of once a month. There was no documented evidence of Chaplain visit for the month of January 2024 or documentation of why the visit was missed. The clinical record lacked evidence of Chaplain notes in the Interdisciplinary Group Meetings on 01/17/2024 or 01/29/2024. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. A Physician's Order dated 01/01/2024 for a Chaplain visit frequency of once a month. There were no Chaplain visits documented from 01/01/2024 to 02/29/2024. There was no documentation of a missed visit and no note regarding any missing Chaplain visits in the Interdisciplinary Group Meetings 01/05/2024, 01/17/2024, 01/29/2024, or 02/12/2024. During an interview with the Director of Nurse and the Administrator on 02/29/2024, no evidence could be produced for the missed Chaplain visits.

It is required that hospice aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. Homemaker services must be provided by individuals who meet the personnel requirements specified in paragraph (j) of this section. Hospice aide provides services; ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice failed to ensure the hospice registered nurse (RN) provided complete and patient-specific instructions to the hospice aide {HCDT.15. I/L625}; Failed to ensure that the Hospice Aide completed visits and/or documented those visits in the same frequency as the patient's Plan of Care ordered {HCDT.16. I/L626}; and Failed to ensure that the RN documented supervision of the Hospice Aide every fourteen days {HSRM.25. I/L629}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a registered nurse who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 12 (17%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency did not ensure the hospice registered nurse (RN) provided complete and patient-specific instructions to the hospice aide. The agency policy Hospice Aide Services (Reference #14.22.1) effective 07/13/2022 included in part that "... The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide of the patient-specific care to be provided. The hospice aide's services are reviewed in the IDG (Interdisciplinary Group Meeting), included in the patient's plan of care..." The hospice's policy Hospice Aide Supervision (Reference #14.21.1) effective 07/13/2022 read in part "...The supervisory visits are documented in the patient's clinical record every two weeks and include notations ... whether the aide is following the patient's plan of care..." The policy Timely Submission of Patient Documentation (Reference #11.05.1) effective 03/21/2021 included in part "The agency will ensure timely and proper submission of patient documentation ...Clinical documentation will be complete and submitted within 24 hours from patient encounter..." Clinical Record 12: The patient elected the hospice benefit on 04/20/2023. There was a Physician's Order dated 01/01/2024 for Hospice Aide visits four times a week, effective 01/28/2024. Hospice Aide visits were documented four times a week the week of 01/01/2024 and five times a week from 01/08/2024 to the week of 01/28/2024. The week of 02/04/2024 there were four Aide visits documented and five Aide visits documented the week of 02/11/204.The clinical record lacked evidence of a hospice aide care plan for visits from 01/02/2024 to 02/16/2024. The Hospice Aide Visit Notes contained only the visit date, the time in and time out of the visit, and the mileage. There were no interventions, no interventions documented as completed, and no narrative. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. A Physician's Order dated 01/01/2024 for Hospice Aide visits three times a week. On 02/29/2024, an order was written for Hospice Aide visits five times a week. The patient had a right medial stage 3 pressure ulcer (3.92 x 5.22 x 0.11) with orders for dressings changes by an outside wound care consultant to cleanse the wound with cleaner and pat dry with gauze. Apply skin prep to the peri-wound. Apply topical antibiotic spray and Therahoney to the wound bed, followed by alginate. Cover with foam and silicone-bordered dressing three times a week and as needed when soiled or loose. Wound Pros clinician to change once weekly and the agency/caregiver twice a week and available as needed for soiled or loose dressing changes. The patient also had a right lateral lower leg venous stasis ulcer (8.69 x 18.67 x 0.11) with orders for dressing changes by an outside wound consultant to cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by collagen and oil emulsion gauze. Cover with absorbent pad dressing and wrap with rolled gauze three times a week and as needed for soiled or loose dressing. Secure the dressing with tape as needed. Wound Pros clinician to change once weekly and the agency/caregiver twice weekly and be available to change soiled or loose dressing. The Hospice Aide Care Plan does not include instructions from the RN to the Aide about what to do with the patient's wounds/dressings if they become wet or soiled during the Hospice Aide visit. It was confirmed during interviews with the Director of Nursing on 02/28/2024 and 02/29/2024 that Clinical Record #2 did not have a Hospice Aide Care Plan documented and that Clinical Record #6 did not include instructions to the Aide regarding the patient's wounds.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 12 (50%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency did not ensure that the Hospice Aide completed visits and/or documented those visits in the same frequency as the patient's Plan of Care ordered. The agency policy Hospice Aide Services (Reference #14.22.1) effective 07/13/2022 included in part that "... The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide on the patient-specific care to be provided. The hospice aide's services are reviewed in the IDG (Interdisciplinary Group Meetings), included in the patient's plan of care ..." The hospice policy Hospice Aide Supervision (Reference #14/21/1) effective date of 07/13/2022 read in part that "...The supervisory visits .... include ... whether the aide is following the patient's plan of care... Clinical Record 2: The patient elected the hospice benefit on 03/23/2022. An order documented on 01/01/2024 included the patient's Hospice Aide frequency for three times weekly. The week of 01/01/2024 there was only one Aide Visit documented on 01/05/2024 (2 missing). There were no Hospice Aide visits documented the weeks of 01/14/2024 and 01/21/2024 (3 missing each week). On 01/22/2024 there were two orders for the Hospice Aide to visit once/one time to equal two Aide visits. Again, there were no Hospice Aide visits this week. Then on 01/28/2024 the order read for the Hospice Aide to visit once/one time to equal one Aide visit. Documented on 01/29/2024 was another order for a one visit/one time Hospice Aide Visit. The week of 01/28/2024, there was one Aide visit documented on 01/29/2024. There was an order on 02/01/2024 for a Hospice Aide frequency of three times weekly. The week of 02/04/2024, there was one Aide visit documented on 02/10/2024 (missing 2 visits). The week of 02/11/2024 there were two Aide visits documented on 02/14/2024 and 02/16/2024. Clinical Record 8: The patient elected the hospice benefit on 01/12/2024. An order documented on 01/12/2024 included the Hospice Aide frequency of three times weekly. Then on 01/21/2024 there was another order documenting Hospice Aide visits three times a week. There were no Aide visits until the week of 01/21/2024. Aide visit was documented on 01/26/2024 - missing two visits that week. Then the week of 01/28/2024 there were Hospice Aide visit documented on 01/29/2024 and 02/02/2024 - missing one visit that week. The week of 02/04/2024 there were no Aide visits documented. Clinical Record 9: The patient elected the hospice benefit on 12/22/2023. On 01/01/2024, a Physician's Order was documented for Hospice Aide visits three times a week. It also included one Hospice Aide visit five times to equal five Aide visits. On 01/08/2024, a Physician's Order was documented for Hospice Aide visits twice weekly. There were no Hospice Aide visits during the weeks of 01/01/2024, 01/07/2024, and 01/14/2024 Beginning the week of 01/21/2024, there were five Hospice Aide visits a week, but the order for five times weekly wasn't documented until 02/01/2024. Clinical Record 10: The patient elected the hospice benefit on 01/18/2024. A Physician's Order dated 01/21/2024 documented twice weekly Hospice Aide visits. The week of 01/21/2024, one Aide visit was documented on 01/25/2024 - missing one visit. The week of 01/28/2024, one Aide visit was documented on 01/30/2024 - missing one aide visit. Clinical Record 11: The patient elected the hospice benefit on 09/28/2023. A Physician's Order dated 01/21/2024 documented the Hospice Aide frequency three times weekly. There were no Hospice Aide visits documented until the week of 02/04/2024. Clinical Record 13: The patient elected the hospice benefit on 04/22/2022. A Physician's Order dated 01/15/2024 documented the Hospice Aide frequency three times weekly. Another Physician's Order was documented on 01/28/2024 for Hospice Aide visits three times a week. There were no Aide visits documented in the week of 01/15/2024, 01/21/2024, and the week of 2/4/2024. During an interview with the Director of Nursing (DON) on 02/27/2024, 02/28/2024, and 02/29/2024, she stated that many visit notes were likely not documented yet and that she just found out recently that one of the Hospice Aides could not yet access the new Electronic Medical Record (EMR) on her portable device.

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. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 12 (33%) clinical records reviewed revealed the agency did not ensure that the RN documented supervision of the Hospice Aide every fourteen days. The agency policy Hospice Aide Supervision (#14.21.1) effective 07/13/2022 included in part that "... A registered nurse makes an on-site visit to the patient's home no less frequently than ever 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient's need...The supervisory visits are documented in the patient's clinical record every 2 weeks ..." The hospice's policy Timely Submission of Patient Documentation (Reference #11.05.1) effective 03/12/2021 read in part that "The agency will ensure the timely and proper submission of patient documentation... Clinical documentation will be complete and submitted within 24 hours from patient encounter..." Clinical Record 2: The patient elected the hospice benefit on 03/23/2022. An order documented on 01/01/2024 included the patient's Hospice Aide frequency three times weekly. The week of 01/01/2024, only one Aide Visit was documented on 01/05/2024 (2 missing). There were no Hospice Aide visits documented the weeks of 01/14/2024 and 01/21/2024 (3 missing each week). On 01/22/2024, there were two Physician's Orders each for the Hospice Aide to visit once/one time to equal two Aide visits. There were no Hospice Aide visits this week. Then on 01/28/2024 a Physician's Order documented for the Hospice Aide to visit once/one time to equal one Aide visit. On 01/29/2024 was another one-visit/one-time Hospice Aide Visit order. The week of 01/28/2024, there was one Aide visit documented on 01/29/2024. A Physician's Order dated 02/01/2024 for a Hospice Aide frequency of three times weekly. The week of 02/04/2024, one Aide visit was documented on 02/10/2024 (missing 2 visits). During the week of 02/11/2024, two Aide visits were documented on 02/14/2024 and 02/16/2024. There was no documented evidence of aide supervisory visits by the RN 1/10/2024, 1/23/2024, 1/28/2024, 2/6/2024, and 2/17/24. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. A Physician's Order dated 01/01/2024 documented Hospice Aide visits three times weekly. Then on 01/21/2024 another Physician's Order increased the Hospice Aide frequency to five times a week. Beginning the week of 01/01/2024, there were Hospice Aide visits three times a week. During the week of 01/28/2024, there were four Hospice Aide visits documented. Then, in the week of 02/04/2024, five Aide visits were documented. The last RN visit documented was 01/29/2024 and included Hospice Aide supervision. The next Aide supervision should have been performed on 02/12/2024. Clinical Record 8: The patient elected the hospice benefit on 01/12/2024. A Physician's Order documented 01/12/2024 included the Hospice Aide frequency of three times weekly. Then on 01/21/2024 there was another order documenting Hospice Aide visits three times a week. There were no Aide visits until the week of 01/21/2024. The Aide visit was documented on 01/26/2024 - missing two visits that week. Then the week of 01/28/2024 there were Hospice Aide visit documented on 01/29/2024 and 02/02/2024 - missing one visit that week. The week of 02/04/2024 there were no Aide visits documented. The RN visits were dated 1/12/2024, 1/26/2024 but did not include documentation of aide supervision. Clinical Record 10: The patient elected the hospice benefit on 01/18/2024. A Physician's Order documented on 01/21/2024 included twice weekly Hospice Aide visits. The week of 01/21/2024, one Aide visit was documented on 01/25/2024 - missing one visit. The week of 01/28/2024, one Aide visit was documented on 01/30/2024 - missing one aide visit. There were documented RN visits on 01/18/2024, 01/29/2024, 01/24/2024, and 01/30/2024 none of which included documentation of hospice aide supervision. During interviews with the Director of Nursing on 02/27/2024, 02/28/2024, and 02/29/2024 it was confirmed that the Hospice Aide Supervisory visits above were not documented in the clinical record. The DON did state that the visits were made but the documentation was not yet submitted and present in the clinical record. The DON and the Administrator further explained that in the switch from the prior Electronic Medical Record System (EMR) to the new EMR there have been struggles.

The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that the Hospice Election of Benefits form was completed with the effective date of the patient's hospice election. Agency Policy: Timely Submission of Patient Documentation (Reference #11.05.1) effective 03/12/2021 "The agency will ensure timely and proper submission of patient documentation ... All documentation related to patient care will be complete and submitted." Medical Record Content (Reference #11.01.1A) effective 03/21/2021 "...The agency will provide an accurate and current medical record for every patient seen by the Agency ... The record is complete, promptly and accurately documented ... Each patient's clinical record includes ...signed copies of the notice of patient rights and election statement..." Clinical Record 5: The patient elected the hospice benefit on 01/22/2023. The effective date of the hospice election on page one of the Informed Consent and Election of Hospice Benefit document was left blank. There was the only part of the consent forms where there was a place to document the effective date of election. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022.The effective date of the hospice election on page one of the Informed Consent and Election of Hospice Benefit document was left blank. There was the only part of the consent forms where there was a place to document the effective date of election. Clinical Record 18: The patient elected the hospice benefit on 10/13/2022. The effective date of the hospice election on page one of the Informed Consent and Election of Hospice Benefit document was left blank. There was the only part of the consent forms where there was a place to document the effective date of election. In an interview and joint document review with the Administrator on 02/29/2024, she confirmed that the effective date of the hospice election was missing/blank from the Informed Consent and Hospice Election forms as presented in evidence. The Administrator stated that ongoing, after training, the admission nurses will complete the admission forms in the Electronic Medical Record (EMR).

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which there was a live discharge from the hospice agency revealed the agency did not ensure that the patient's discharge summary was forwarded to the Medicare certified facility upon discharge. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022 and revoked the hospice benefit on 01/26/2024. The Discharge Summary documented the patient's demographics and hospice diagnosis, medication allergies, which disciplines were vising the patient, but not the frequency of visits, the plan of care, the medication list, summary of care, or physician orders. There was an Administrative Clinical Summary note that had a box checked that the patient's primary physician was called, but patient revoked services to go to the hospital for surgical correction of a fracture. There was no documented evidence that any of the required information was sent to either the attending physician or the hospital where the patient was admitted for care. During an interview and joint record review with the Director of Nursing (Staff 2) and the Administrator (Staff 1) on 02/28/2024 confirmed that there was no information documented in the patient's medical record that the patient's Discharge Summary was sent to the receiving hospital or to the patient's attending physician.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which there was a live discharge from the hospice agency revealed the agency did not ensure that the patient's discharge summary was forwarded to the Medicare certified facility upon discharge. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022 and revoked the hospice benefit on 01/26/2024. The Discharge Summary documented the patient's demographics and hospice diagnosis, medication allergies, which disciplines were vising the patient, but not the frequency of visits, the plan of care, the medication list, summary of care, or physician orders. There was an Administrative Clinical Summary note that had a box checked that the patient's primary physician was called, but patient revoked services to go to the hospital for surgical correction of a fracture. There was no documented evidence that any of the required information was sent to either the attending physician or the hospital where the patient was admitted for care. During an interview and joint record review with the Director of Nursing and the Administrator on 02/28/2024 confirmed that there was no information documented in the patient's medical record that the patient's Discharge Summary was sent to the receiving hospital or to the patient's attending physician.

It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the patient's full name, generic, trade, or brand name of the medication, as well as amount dispensed, directions for use, including route, rate, frequency, and method of administration, prescriber’s name, expiration date, and cautionary instructions. This standard was not met as evidenced by clinical record review and observation. In 1 of 4 (25%) home visits observed revealed the agency did not ensure that the patient's medication was labeled with the required information. Home Visit 3: The patient elected the hospice benefit on 02/12/2023. During the home visit observation with the registered nurse (Personnel Record 5) on 02/28/2024, the patient's son and primary caregiver brought the patient's medications to the patient's room for the RN to review. These medications included what the son reported to be Hydrocodone/Acetaminophen. The Hydrocodone was in a bottle with a label completely faded without the patient's name visible, the name of the medication, or the directions and frequency of use. There was no medication list in the patient's home. When questioned, the RN responded she would have to print one but that I could look at the chart on her iPad. Upon record review, the patient's medication list had documented both the Hydrocodone/Acetaminophen 5/325mg: one by mouth every four hours as needed for pain listed as discontinued. The nurse verified with the son that the patient was taking the Hydrocodone.