Every finding on record at Peace Hospice and Palliative Care, Inc.

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 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the hospice interdisciplinary group completed an initial comprehensive assessment no later than five calendar days after the election of hospice care. Clinical Record 5: The election of the hospice benefit was 06/05/2024. The initial social work assessment was dated 09/21/2024, 16 days after the election of the hospice benefit. The clinical record did not include documentation of a reason for the late assessment. Clinical Record 13: The election of the hospice benefit was 09/19/2024. The initial social work assessment was dated 09/25/2024, 6 days after the election of the hospice benefit. The clinical record did not include documentation of a reason for the late assessment. During an interview on 11/13/2024, the Director of Clinical Services reviewed the records and stated, "There are no notes to indicate why the assessments were late."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. Agency policy #PC.85 "Medication List and Monitoring" (dated 09/01/2024) stated in part, "The Hospice Registered Nurse will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all hospice staff involved in the patient's care, including the pharmacist. A medication/drug profile will be maintained on all patients. Medication monitoring will include appropriate data/information to develop an accurate patient medication history and a current, complete medication profile. The hospice will review, monitor, and maintain a current, accurate list of all prescription and over-the-counter medications, herbal remedies, and other alternative treatments that could affect drug therapy taken by the patient." In 11 of 19 (58%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. Clinical Record 5: The election of the hospice benefit was 06/05/2024. The plan of care dated 06/05/2024-09/03/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 06/05/2024 did not document oxygen. Clinical Record 6: The election of the hospice benefit was 10/11/2024. The plan of care dated 10/11/2024-01/09/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 10/11/2024 did not document oxygen. Clinical Record 8: The election of the hospice benefit was 04/16/2024. The plan of care dated 04/16/2024-07/14/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 04/16/2024 did not document oxygen. Clinical Record 9: The election of the hospice benefit was 05/17/2024. The plan of care dated 05/17/2024-08/14/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 05/17/2024 did not document oxygen. Clinical Record 10: The election of the hospice benefit was 10/03/2024. The plan of care dated 10/03/2024-01/01/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 10/03/2024 did not document oxygen. Clinical Record 11: The election of the hospice benefit was 10/03/2024. The plan of care dated 10/03/2024-01/01/2025 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 10/03/2024 did not document oxygen. Clinical Record 12: The election of the hospice benefit was 06/01/2024. The plan of care dated 06/01/2024-08/30/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 06/01/2024 did not document oxygen. Clinical Record 13: The election of the hospice benefit was 09/19/2024. The plan of care dated 09/19/2024-12/17/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 09/19/2024 did not document oxygen. Clinical Record 15: The election of the hospice benefit was 01/05/2024. The plan of care dated 01/05/2024-03/31/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 01/05/2024 did not document oxygen. Clinical Record 16: The election of the hospice benefit was 05/04/2024. The plan of care dated 05/04/2024-05/29/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 05/04/2024 did not document oxygen. Clinical Record 17: The election of the hospice benefit was 01/05/2024. The plan of care dated 01/05/2024-03/01/2024 ordered: "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The drug profile dated 01/05/2024 did not document oxygen. On 11/14/2024, the Director of Clinical Services reviewed the records and confirmed that oxygen was not included in the medication profiles.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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 3 of 19 (16%) clinical records reviewed, the agency did not ensure that all problems identified in the initial and updated comprehensive assessment had planned interventions in the patient's written plan of care. Clinical Record 12: The election of the hospice benefit was 06/01/2024. The initial nursing assessment dated 06/01/2024 documented, "Patient has a history of seizures." The plan of care dated 06/01/2024-08/30/2024 did not include documentation of planned interventions for seizure activity. Clinical Record 16: The election of the hospice benefit was 05/04/2024. A clinical record review revealed a physician's order dated 05/08/2024: "Xarelto (anticoagulant) 20mg tablet by mouth daily." The plan of care dated 05/04/2024-05/29/2024 did not include documentation of planned interventions for the patient's risk for bleeding. Clinical Record 18: The election of the hospice benefit was 02/28/2024. A clinical record review revealed a physician's order dated 02/28/2024: "Eliquis (anticoagulant) 5mg tablet by mouth twice daily." The plan of care dated 02/28/2024-03/17/2024 did not include documentation of planned interventions for the patient's risk for bleeding. In an interview on 11/14/2024, the Director of Clinical Services reviewed the records and stated, "There are no interventions for seizure precautions or bleeding risk."

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 5 of 16 (31%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that hospice aide services were provided as included in the plan of care. Clinical Record 2: The election of the hospice benefit was 10/02/2024. The plan of care dated 10/02/2024 through 12/31/2024 ordered: "CNA 3x/week." One HA visit was documented on 10/04/2024 for the week of 09/29/2024 through 10/05/2024. There was no evidence of documented missed visits. Clinical Record 6: The election of the hospice benefit was 10/11/2024. The plan of care dated 10/11/2024 through 01/09/2025 ordered: "CNA 3x/week." A clinical record review revealed no HA visits for the week of 10/06/2024 through 10/12/2024. There was no evidence of documented missed visits. Clinical Record 11: The election of the hospice benefit was 10/03/2024. The plan of care dated 10/03/2024 through 01/01/2025 ordered: "CNA 3x/week." One HA visit was documented on 10/05/2024 for the week of 09/29/2024 through 10/05/2024. There was no evidence of documented missed visits. Clinical Record 15: The election of the hospice benefit was 01/05/2024. The plan of care dated 01/05/2024 through 03/31/2024 ordered: "CNA 2x/week." A clinical record review revealed no HA visits for the week of 12/31/2023 through 01/06/2024. There was no evidence of documented missed visits. Clinical Record 17: The election of the hospice benefit was 01/05/2024. The plan of care dated 01/05/2024 through 03/01/2024 ordered: "CNA 3x/week starting 01/07/2024." A clinical record review revealed no HA visits for the weeks of 01/07/2024 through 01/13/2024 and 01/14/2024 through 01/20/2024. There was no evidence of documented missed visits. During an interview on 11/14/2024, the Director of Clinical Services reviewed the records, confirmed the findings, and stated, "There are no missed visit notes for these aide visits."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary; [and] the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with a live discharge, the agency did not ensure that a copy of the hospice discharge summary was provided to the patient's attending physician. Clinical Record 15: The election of the hospice benefit was 01/05/2024. A clinical record review revealed a hospice discharge visit note dated 03/31/2024 that documented, "Patient is being discharged due to extended prognosis. The attending physician was notified." The clinical record did not include documentation that the hospice discharge summary was forwarded to the patient's attending physician. During an interview and a joint record review on 11/14/2024, the Director of Clinical Services confirmed that the discharge summary was not sent to the attending physician.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs, Supplements, Herbal remedies and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, Drug side effects, Actual or potential drug interactions, Duplicate drug therapy and Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. 2 of 13 (15%) records reviewed lacked evidence that the medication list included all medications the patient was ordered and lacked evidence that a review process included all current medications being taken by the patient. Record #86640: The record documented that a new medication Tramadol was added to the medication profile on 10/8/2021. A review of the medication regimen was documented as completed on 12/21/2021. The medication review process failed to be completed at the time of the addition of the new medication. Record #60515: The hospice record medication profile reviewed on 1/19/2022 did not match the Skilled Nursing Facility (SNF) Medication Administration Record (MAR), also reviewed on 1/19/22 at 10:35 am. A review of SNF MAR identified that the patient was currently taking Ferrous Sulfate Tablet 325 mg 1 tablet by mouth daily and Lorazepam intensol concentrate 0.25 ml every 6 hours PRN for anxiety since 11/18/2021. These medications were not included on the Hospice medication profile. In addition, the Hospice medication profile included medications of Acetaminophen 650 mg suppository every 6 hours as needed for fever and Baza Antifungal Cream to buttocks To bilateral lower extremities daily with Telfa and ace wrap for dryness which were not included on the SNF MAR. During an interview, the Clinical Director stated during a joint review of the clinical records on 1/20/2022 that the medication profiles were not reviewed upon the addition of new medications ordered and that the Hospice and SNF MAR failed to match. The Clinical Director further stated that the Hospice did have a method of a review process on admission and with each certification period, yet had failed to complete the review process when a new medication was added to the medication regimen.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 41.I; and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency Policy #PE.3 titled Patient Transfer (revised 1/1/20) stated in part, "If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the Agency will forward copies of the following to the receiving facility: The hospice discharge summary and the patient's clinical record, if requested." 1 of 2 (50%) records reviewed for patients that transferred care to a Medicare/Medicaid certified facility out of 13 total records reviewed lacked documentation that the Discharge Transfer summary was forwarded to the receiving facility. Record #97987: The patient was transferred to a hospital setting on 11/23/2021. The record lacked evidence that the completed Discharge summary was forwarded to the receiving facility. This finding was verified through an interview with the Clinical Director during a joint review of the clinical record on 1/20/2022, who stated that the agency had not forwarded the Discharge summary to the receiving facility.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group: ensures that the safe use and disposal of controlled drugs is understood. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency Policy # PC.19, titled Medication Disposal (revised 3/1/21), stated in part, "The Hospice will not remove any medications from patient's home or dispose of patient's medications. If Hospice staff provides verbal assistance with disposal, the staff will document in the patient's clinical record the medication, dosage, route of administration, quantity so disposed and the time, date, and manner in which that disposal occurred." 2 of 2 (100%) records reviewed for patients requiring the documentation of controlled drug disposal out of 13 total clinical records reviewed revealed the skilled nurse failed to document the disposal of controlled medications in accordance with agency policy. Record #73028: the death visit documentation dated 12/18/2021 completed by the Registered Nurse (RN) documented that the RN completed medication destruction with the daughter as a witness. Documentation also lacked which medications were destroyed, the quantity, and the time and manner in which the medications were destroyed. Record #45618: the death visit documentation dated 1/18/2022 completed by the Registered Nurse (RN) documented that the RN completed medication destruction with the son as a witness. Documentation also lacked which medications were destroyed, the quantity, and the time and manner in which the medications were destroyed. This finding was verified through an interview with the Clinical Director during a joint review of the records on 1/20/2022, who stated that these records documented that the RN destroyed the medications, which is not in adherence with agency policy and failed to document which medications were destroyed, the quantity destroyed, the time of destruction and the method of destruction.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent Hospice plan of care, Hospice election form and any advance directives, Physician certification, and recertification of the terminal illness, Hospice medication information, and Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by a review of clinical records, observation, and interview. Agency Policy #PC.25, titled Hospice Care in an SNF/NF or ICF/IID (revised 10/1/19), stated in part, "The Agency will provide the Facility with the following hospice information/documentation on admission and on-going: All Plans of Care and Comprehensive assessment documents, The Hospice Election form and any advance directives, The physician certification and recertification of the terminal illness, Hospice medication information, The Hospice physician and attending physician orders, Copies of clinical notes after each visit." 1 of 1 (100%) records reviewed during a home visit observation for a patient residing in a skilled nursing facility (SNF) out of 13 total records reviewed lacked evidence that the hospice had provided the SNF with all required documentation. Record #60515: Hospice documentation provided to the SNF was reviewed during observation during a home visit on 1/19/2022 at 10:35 am. The patient was admitted to service on 6/8/2021 and resided in the SNF during the entire length of stay with the hospice. The facility record lacked evidence of signed consents, the Physician's Certification of Terminal Illness and Recertification of Terminal Illness, hospice medication information, hospice physician orders, copies of the clinical notes after each visit, and the current plan of care (POC). The POC present in the clinical record was dated 7/14/2021. During a joint review of the SNF Hospice documentation, the visiting nurse (Record #19730) stated that these required documents were not present in the SNF Hospice record.