Every finding on record at Principle Hospice Service LLC

Based on record review and interview, the agency failed to include in the plan of care, all services necessary services for the palliation and management of the terminal illness and related condition including drugs and treatment necessary to meet the need of the patient, in that wound care treatment was not included in the plan of care for 1 (Patient #11) of 3 patient records reviewed where the patient received wound care.  The failure placed the patient at risk of wound infection or worsening of wounds. --- Patient #11: Record review of Patient #11's clinical record revealed a Plan of Care Dated 4/4/2025 to 6/2/2025. The Plan of Care listed Transient Cerebral Ischemic Attack and related syndromes (brief blockage of blood flow to the brain with symptoms that mimic a major stroke—sudden numbness, slurred speech, or vision loss) as the terminal diagnosis. The Plan of Care did not contain orders for wound care. Registered Nurse D conducted an initial comprehensive assessment on 4/4/2025. Registered Nurse D documented that Patient #11 had wound to the sacral coccyx (lower back) that measured 3 x 3 x 1 centimeters. Registered Nurse D documented wound care, per Physician X, cleaned with normal saline (fluid matching the body's natural salt and water balance used to clean wounds), patted dry, apply betadine (used to disinfect minor cuts, scrapes, and burns, and prevent infections) to wound and cover with border foam dressing (sterile, multi-layered wound care product featuring a soft, highly absorbent central foam pad and surrounding adhesive border). Registered Nurse D documented that Patient #11 had a wound to the left heel that measured 2 x 3 centimeters. Registered Nurse D documented cleaning the left heel wound, per Physician X, with normal saline, patted dry, apply betadine, and covered with bordered foam dressing.  Licensed Vocational Nurse E conducted a skilled nurse visit on 4/15/2025. Licensed Vocational Nurse E documented that wound care was performed as physician ordered. Licensed Vocational Nurse E conducted a skilled nurse visit on 4/22/2025. Licensed Vocational Nurse E documented that wound care was performed as physician ordered.  Patient #11 died on 4/30/2025. Patient #11's clinical record contained Plans of Care dated 4/11/2025, and 4/25/2025. The Plans of Care contained an order that the registered nurse would perform wound care as ordered by the physician. Patient #11's Plan of Care did not include the wound care treatment to be provided for Patient #11. Registered Nurse D was no longer employed at the agency. During an interview on 6/25/2026 at 1:51 PM with the Alternate Administrator/Supervising Nurse, the Surveyor discussed that nursing staff were performing wound care treatments to Patient #11 and Patient #11's Plan of Care did not include wound care treatments. The Surveyor asked who would be responsible to ensure that the Plan of Care included wound care. The Alternate Administrator/Supervising Nurse said, "It would be the Registered Nurse that was seeing the patient." The Surveyor discussed that Patient #11 received a visit by a Registered Nurse for the admit visit and for the discharge visit. The Surveyor asked who would be responsible to ensure the Plan of Care included wound care treatment if the licensed vocational nurse was seeing the patient. The Alternate Administrator/Supervising Nurse informed the Surveyor that the nurse would call the physician to get orders. The Alternate Administrator/Supervising Nurse stated, "It was an error that it was not on the Plan of Care."  During an interview on 6/26/2026 at 1:43 PM with Licensed Vocational Nurse E. the Surveyor discussed the wound care performed for Patient #11. The Surveyor asked Licensed Vocational Nurse E how would Licensed Vocational Nurse E would know what the wound care would be for a patient. Licensed Vocational Nurse E stated, "By a physician's order or if they had been at the hospital." The Surveyor asked what if there were no order for wound care in the chart. Licensed Vocational Nurse E informed the Surveyor that it would be communicated to Licensed Vocational Nurse E. The Surveyor asked if the admitting nurse would communicate to Licensed Vocational Nurse E. Licensed Vocational Nurse E stated, "Yes." The Surveyor asked if Licensed Vocational Nurse remembered what the wound care for Patient #11 had been. Licensed Vocational Nurse E did not remember the wound care.  Licensed Vocational Nurse E called the Surveyor on 6/26/2026 at 2:56 PM. Licensed Vocational Nurse E informed the surveyor that the wound care order was in the Initial Comprehensive Assessment done by Registered Nurse D. Licensed Vocational Nurse E had informed the Surveyor that Registered Nurse D was not communicative with Licensed Vocational Nurse E. The Surveyor asked if the nursing note was the Plan of Care. Licensed Vocational Nurse E stated, "No."  Review of the agency's policy titled "Plan of Care Process PC.30," last reviewed on 3/16/2026 read in part; "Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family' specific needs. Policy I. All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with the Attending Physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient's needs...Procedure...VI. The POC includes, but is not limited to...D. Drugs and treatments necessary to meet the needs of the patient..."

Based on record review and interview, the interdisciplinary group- core group of a physician, registered nurse, chaplain, and social worker that provided/supervised all care and services, ensuring a holistic approach to terminal illness and bereavement, (in collaboration with the individual's attending physician, if any) failed to review, revise and document the patient's individualized plan of care as frequently as the patient's condition required but no less frequently than every 15 days, in that the interdisciplinary group failed to revise the plan of care regarding wound care for 2 (Patient #5, Patient #11) of 3 records reviewed where the patient received wound care, and/or failed to revise frequency of visits for 6 (Patient #5, Patient #6, Patient #9, Patient #11, Patient #12, Patient #13) of 14 patient records reviewed.  The failure placed patients at risk of wounds becoming infected or worsening, and spiritual or psychosocial needs not being identified or going unmet. --- WOUNDS Patient #5:Patient #5's clinical record contained a Plan of Care dated 3/27/2026. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery with unspecified Angina Pectoris (natural arteries supplying blood to the heart are narrowed and hardened by fatty plaque buildup causing chest pain) as the terminal diagnosis. The Plan of Care contained an order for wound care to Patient #5's right ankle wound to be cleaned with warm soapy water, apply Silvadene (prescription-strength topical cream used to prevent and treat infections in severe second- and third-degree burns) twice a day, and leave open to air.  Record review of Patient #5's clinical record revealed an Initial Comprehensive assessment that indicated that Patient #5 started on the hospice's services on 2/7/2026. Registered Nurse C conducted a recertification comprehensive assessment on 3/28/2026. Registered Nurse C documented that the wound to Patient #5's right ankle wound was closed. Patient #5 was discharged on 6/2/2026. Patient #5's clinical record contained Plans of Care dated 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The Plans of Care contained the order to clean the right ankle wound with warm soapy water, apply Silvadene twice a day and leave open to air. The interdisciplinary group met on 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The interdisciplinary group failed to revise the Plans of Care to remove the wound care to Patient #5's right ankle.  Patient #11: Record review of Patient #11's clinical record revealed a Plan of Care Dated 4/4/2025 to 6/2/2025. The Plan of Care listed Transient Cerebral Ischemic Attack and related syndromes (brief blockage of blood flow to the brain with symptoms that mimic a major stroke—sudden numbness, slurred speech, or vision loss) as the terminal diagnosis. The Plan of Care did not contain orders for wound care. Registered Nurse D conducted an initial comprehensive assessment on 4/4/2025. Registered Nurse D documented that Patient #11 had wound to the sacral coccyx (lower back) that measured 3 x 3 x 1 centimeters. Registered Nurse D documented wound care, per Physician X, cleaned with normal saline (fluid matching the body's natural salt and water balance used to clean wounds), patted dry, apply betadine (used to disinfect minor cuts, scrapes, and burns, and prevent infections) to wound and cover with border foam dressing (sterile, multi-layered wound care product featuring a soft, highly absorbent central foam pad and surrounding adhesive border). Registered Nurse D documented that Patient #11 had a wound to the left heel that measured 2 x 3 centimeters. Registered Nurse D documented cleaning the left heel wound, per physician X, with normal saline, patted dry, apply betadine, and covered with bordered foam dressing.  Licensed Vocational Nurse E conducted a skilled nurse visit on 4/15/2025. Licensed Vocational Nurse E documented that wound care was performed as physician ordered. Licensed Vocational Nurse E conducted a skilled nurse visit on 4/22/2025. Licensed Vocational Nurse E documented that wound care was performed as physician ordered.  Patient #11 died on 4/30/2025. Patient #11's clinical record contained Plans of Care dated 4/11/2025, and 4/25/2025. The Plans of Care contained an order that the registered nurse would perform wound care as ordered by the physician. The interdisciplinary group met on 4/11/2025 and 4/25/2025. The interdisciplinary group failed to revise the Plans of Care to include the specific physician ordered wound care to Patient #11's wounds.    VISIT FREQUENCY Patient #5:Patient #5's clinical record contained a Plan of Care dated 4/7/2026 to 6/2/2026. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery with unspecified Angina Pectoris as the terminal diagnosis. The Plan of Care contained orders for Chaplain visits once a month for 3 months and Social Work visits once a month for 2 months.  Record review of Patient #5's clinical record revealed an Initial Comprehensive assessment that indicated that Patient #5 started on the hospice's services on 2/7/2026.   Patient #5 last Chaplain visit was on 3/11/2026. Patient #5 did not receive a Chaplain visit in April 2025, or May 2025. Patient #5 did not receive a visit from a Social Worker while on the hospice's services. The Plans of Care dated 3/27/2026, 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026 contained orders for Patient #5 to receive Chaplain visits once a month for 3 months and Social Work visits once a month for 2 months.  The interdisciplinary group met on 3/28/2026, 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The interdisciplinary group failed to revise the Plans of Care for the frequency of Chaplain and Social Work visits.  Patient #6:Record review of Patient #6's clinical record revealed a Plan of Care dated 3/27/2026. The Plan of Care listed Senile Degeneration of the Brain (decline in memory and reasoning) as the terminal diagnosis. The Plan of Care contained an order for Patient #6 to receive a Chaplain visit once a month for 3 months.  Patient #6's clinical record contained consents with the election date for service of 1/31/2026.  Patient #6's last Chaplain visit was on 3/19/2026. Patient #6 did not receive a Chaplain visit in April 2026.  Patient #6 was discharged 5/26/2026. Patient #6's clinical record contained Plans of Care dated 4/10/2026, 4/17/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The Plans of Care contained an order for Patient #6 to receive a Chaplain visit once a month for 3 months.  The interdisciplinary group met on 4/10/26, 4/17/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The Interdisciplinary group failed to revise the Plans of Care for the frequency of Chaplain visits.   Patient #9:Record review of Patient #9's clinical record contained a Plan of Care dated 3/27/2026. The Plan of Care listed Alzheimer's Disease (progressive, irreversible brain disorder that destroys memory, thinking skills, and the ability to carry out simple daily tasks) as the terminal diagnosis. The Plan of Care contained orders for Patient #9 to receive Chaplain visits once a week and Social Work visits once a month. Patient #9's record contained consents that indicated the election date for hospice services was 1/31/2026. Patient #9's clinical record contain Chaplain visits conducted on 2/13/2026 and 3/25/2026. Patient #9 did not receive Chaplain visits weekly.  Patient #9's clinical record indicated that Patient #9 had not received a Social Work visit while on service. Patient #9 was discharged on 5/30/2026. Patient #9's clinical record contained Plans of Care dated 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The Plans of Care contained an order for Patient #9 to receive a Chaplain visit once a week and Social Work visits once a month.  The interdisciplinary group met on 4/10/26, 4/24/2026, 5/8/2026, and 5/22/2026. The Interdisciplinary group failed to revise the Plan of Care for the frequency of Chaplain visits and the frequency of Social Work visits.   Patient #11:Record review of Patient #11's clinical record revealed a Plan of Care Dated 4/4/2025 to 6/2/2025. The Plan of Care listed Transient Cerebral Ischemic Attack and related syndromes (brief blockage of blood flow to the brain with symptoms that mimic a major stroke—sudden numbness, slurred speech, or vision loss) as the terminal diagnosis. The Plan of Care contained an order for Patient #11 to receive Chaplain and Social Work visits once a week.  Patient #11's clinical record contained documentation of a Social Work visits by Social Worker G on 4/8/2025. Patient #11's clinical record did not indicate that Patient #11 received a Social Work visit weekly. Patient #11's clinical record did not indicate that Patient #11 received a Chaplain visit while on services.  Patient #11 died on 4/30/2025. Patient #11's clinical record contained Plans of Care dated 4/11/2025 and 4/25/2025. The Plans of Care contained orders for Patient #11 to receive Chaplain and Social Work visits once a week. The interdisciplinary group met on 4/11/25 and 4/25/2025. The Interdisciplinary group failed to revise the Plans of Care for the frequency of Chaplain visits and the frequency of Social Work visits.   Patient #12: Record review of Patient #12's clinical record revealed a Plan of Care dated 8/13/2025. The Plan of Care listed Other Alzheimer's Disease (brain disorder characterized by the buildup of abnormal proteins that destroy memory and thinking) as the terminal diagnosis. The Plan of Care contained an order for Patient #12 to received Aide visits 5 times each week.  Review of Patient #12's clinical record revealed that 10/1/2025 was the last day that Patient #12 received an Aide visit.  Patient #12 died 10/14/2025. Patient #12's clinical record contained a Plans of Care dated 9/26/2025, 10/9/2025, and 10/12/2025. The Plans of Care contained an order for Patient #12 to receive Aide visits 5 times each week.  The interdisciplinary group met on 9/26/2025 and 10/9/2025. The interdisciplinary group failed to revise the Plans of Care for the change in frequency of Aide visits.   Patient #13:Record review of Patient #13's clinical record revealed a Plan of Care dated 2/14/2025. The Plan of Care Listed Senile Degeneration of the Brain (decline in memory and reasoning) as the terminal diagnosis. The Plan of Care contained an order for Patient #13 to receive Chaplain visits once a month.  Chaplain F conducted a Chaplain visit on 4/2/2025. The visit on 4/2/2026 was the only visit conducted by a chaplain since Patient #13 was admitted to services. Patient #13's record did not indicate that Patient #13 received a chaplain visit in February 2025 or March 2025. Patient #13 died on 4/8/2025. Patient #13's clinical record contained Plans of Care dated 2/28/25, 3/14/25, and 3/27/2025. The Plans of Care contained an order for Patient #13 to receive Chaplain visits once a month. The Interdisciplinary group met on 2/14/2025, 2/28/2025, 3/14/2025, and 3/28/2025. The Interdisciplinary group failed to revise the Plans of Care for Chaplain frequency.   During an interview on 6/25/2026 at 1:51 PM with the Alternate Administrator/Supervising Nurse, the Surveyor discussed the Plans of Care not being revised regarding wound care and frequency of visits by staff. The Surveyor asked who was responsible to revise the Plans of Care. The Alternate Administrator/Supervising Nurse stated that the registered nurse case manager would be responsible but that ultimately it would be the Alternate Administrator/Supervising Nurse. The Surveyor asked how the agency conducted interdisciplinary group meetings. The Alternate Administrator/Supervising Nurse informed the Surveyor that it was done at the physician's home and others would be on zoom. The Plan of Care would be visualized by projector. The Alternate Administrator/Supervising Nurse would look into the staff frequencies. The Alternate Administrator/Supervising Nurse did not know why the Plans of Care had not been revised. The Alternate Administrator/Supervising Nurse had informed the Surveyor that there had been clinical issues at one of the Alternate Delivery Sites and that they had transferred their patients to other hospices at that Alternate Delivery Site. The Alternate Administrator/Supervising Nurse informed the Surveyor that Registered Nurse C, Registered Nurse D, and Chaplain F no longer worked at the agency.   During an interview on 6/26/2026 at 1:43 PM with Licensed Vocational Nurse E. the Surveyor discussed the wound care performed for Patient #11. The Surveyor asked Licensed Vocational Nurse E how would Licensed Vocational Nurse E would know what the wound care would be for a patient. Licensed Vocational Nurse E stated, "By a physician's order or if they had been at the hospital." The Surveyor asked what if there were no order for wound care in the chart. Licensed Vocational Nurse E informed the Surveyor that it would be communicated to Licensed Vocational Nurse E. The Surveyor asked if the admitting nurse would communicate to Licensed Vocational Nurse E. Licensed Vocational Nurse E stated, "Yes." The Surveyor asked if Licensed Vocational Nurse remembered what the wound care for Patient #11 had been. Licensed Vocational Nurse E did not remember the wound care.  Licensed Vocational Nurse E call the Surveyor on 6/26/2026 at 2:56 PM. Licensed Vocational Nurse E informed the surveyor that the wound care order was in the Initial Comprehensive Assessment done by Registered Nurse D. Licensed Vocational Nurse E had informed the Surveyor that Registered Nurse D was not communicative with Licensed Vocational Nurse E. The Surveyor asked if the nursing note was a physician order. Licensed Vocational Nurse E stated, "No." Review of the agency's policy titled "Plan of Care Process PC.30," last reviewed 3/16/2026, read in part; "Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs. Policy I. All hospice care and services furnished to patients and their families will follow an individualized written POC, established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with the Attending Physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient's needs. II. The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions...Procedure...VI. The POC includes, but is not limited to...B. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...VII. The Hospice IDG/IDT, in collaboration with the individual's attending physician, if any, will review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently that every 15 calendar days..."

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address informing local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency based on the patient’s medical or psychiatric condition, or home environment. The minimum information provided to facilitate patient evacuation and transportation including if the patient is mobile or not, if the patient has life-dependent equipment, and if so, is it able to be transported (e.g., battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g., deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. 15 of 15 (100%) clinical records reviewed revealed the agency did not ensure that the clinical records contained a patient-specific emergency plan to assist in the evacuation of patients if needed, that included the patient's mobility, equipment needs, the ability to transport equipment, or any specific needs of the patient such as cognitive deficits, hearing or sight loss, or language barriers. Clinical Record 1: The patient elected the hospice benefit on 9/9/2022 and was admitted to hospice services with a terminal diagnosis of Senile Degeneration of the Brain that impacted cognition and the patient's ability to sign consents for hospice care. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 2: The patient elected the hospice benefit on 1/23/2022. Per the RN Skilled Nurse Visit on 3/7/2023, the patient was only alert and oriented x2 and required moderate to maximum assistance with activities of daily living. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 3: The patient elected the hospice benefit on 12/21/2022. The patient was admitted to hospice services for the terminal diagnosis of Senile Degeneration of the Brain which affected the patient's cognitive status to the extent that the patient was unable to sign consent for hospice care. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 4: The patient elected the hospice benefit on 10/13/2020. The patient was admitted to hospice care with a terminal diagnosis of the effects of a Cerebrovascular Accident, causing the patient to have decreased cognitive abilities to the extent the patient was unable to sign consent for hospice care. Additionally, a physician order dated 1/20/2023 ordered oxygen at 2 liters per minute per nasal cannula. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 5: The patient elected the hospice benefit on 12/9/2022. The patient was admitted to hospice care with a terminal diagnosis of lung cancer. The RN Recertification Visit dated 3/6/2023 documented the use of oxygen per nasal cannula at 2 liters per minute with increasing weakness affecting the mobility and endurance of the patient. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 6: The patient elected the hospice benefit on 6/2/2022. The patient was admitted to hospice care with a terminal diagnosis of Senile Degeneration of the Brain. The patient's cognitive ability was affected to the extent that the patient could not sign consents for hospice care. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 15: The patient elected the hospice benefit on 10/7/2022. The RN Initial Assessment Visit on 10/7/2022 included documentation that the patient was admitted to hospice with the terminal diagnosis of Chronic Obstructive Pulmonary Disease and was dependent on oxygen. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 7: The patient elected the hospice benefit on 12/10/2022. The RN Recertification Visit on 4/25/2023 included documentation that the patient requires total care for all activities of daily living and is bedbound. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 8: The patient elected the hospice benefit on 9/26/2022. The physician's Certification of Terminal Illness dated 4/29/2023, the patient is non-ambulatory and requires the use of a wheelchair but remains in bed for much of the day. The physician states that the patient has no consistent meaningful verbal communication with less than 6 intelligible words during the course of the visit. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 9: The patient elected the hospice benefit on 8/10/2022 and was admitted to hospice with the terminal diagnosis of Senile Degeneration of the Brain with limited cognitive ability. The patient was unable to sign their own consent to be admitted to hospice care on 8/10/2022. The patient's problem list from the Interdisciplinary Group Meeting on 5/9/2023 also included diagnoses of shortness of breath in addition to incontinence, anxiety, and edema. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 10: The patient elected the hospice benefit on 8/10/2022. The RN Recertification Visit on 5/23/2023 included documentation that the patient was alert to self only. The patient had limited speech speaking 3-5 words during the nurse's visit. Additionally, the patient required the use of a PEG tube for enteral feedings due to dysphagia. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 11: The patient elected the hospice benefit on 1/16/2023. The physician's Certification of Terminal Illness dated 4/5/2023 stated the patient's dementia had progressed to the point of only being able to use a few words during the visit. Additionally, the patient requires the use of a non-rebreather mask with continuous oxygen. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 12: The patient elected the hospice benefit on 10/16/2020. The patient was admitted to hospice care with a terminal diagnosis of Alzheimer's disease and was unable to sign consents due to cognitive deficits. The patient was unable to live on their own and required around-the-clock caregivers. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 13: The patient elected the hospice benefit on 10/16/2021. The patient was admitted to hospice care with a terminal diagnosis of severe protein-calorie malnutrition. On 6/14/2023, during the home visit observation, it was noted that the patient spoke only Spanish. The patient had cognitive dysfunction to the extent that they were unable to sign consent for hospice care. The documentation in the clinical record stated the patient needed constant supervision and care. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. Clinical Record 14: The patient elected the hospice benefit on 11/8/2022. The patient elected the hospice benefit with a terminal diagnosis of paroxysmal atrial fibrillation. On 6/13/2023, during the home visit observation, it was noted that the patient was bedbound. Upon review of the clinical record, it was revealed that the clinical record did not include evidence of patient-specific emergency plan documentation or assessment that included the information to relay to emergency officials in case the patient needed to evacuate, such as the mobility level of the patient, or if the patient required any life-sustaining equipment and if so, was the equipment able to be transported. The patient-specific emergency preparedness assessment or plan did not include documentation of whether the patient had any special needs such as cognitive problems, hearing or vision loss, or the need for translation services if the patient does not speak English. During an interview with the Director of Clinical Services on 6/14/2023, it was confirmed that the agency did not have any documentation of patient-specific emergency assessments or plans documented with the criteria required to include information about the patient's mobility status, life-saving equipment, or to document any special communication or sensory issues, such as cognitive deficits, language barriers, or hearing or vision loss.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years with documentation of each training, including the date(s), participants, and content. This standard was not met as evidenced by document review and interview. 2 of 8 (25%) personnel records reviewed revealed the agency did not ensure that emergency preparedness training and education were performed and documented at least every 2 years. Retired Agency Policy "Agency Inservices" (HR.13), with a revised date of 1/1/2020, stated in part, "The agency...will provide the following in services annually...Emergency Preparedness." Current Agency Policy "Personnel Development" (1-011) with the date of January 2023 stated in part, "The agency ...requires that each hospice personnel complete a minimum of the following programs each year...Emergency Preparedness." Personnel Record 1: The Administrator with a date of hire of 3/19/2019 had no evidence of emergency preparedness education or training for 2021 or 2022 located in their personnel file. Personnel Record 8: The Chaplain/Bereavement Coordinator with a date of hire of 3/30/2020 had no evidence of emergency preparedness education or training for 2021 or 2022 located in their personnel file. In an interview on 6/15/2023 with the Director of Clinical Services on 6/15/2023 and after a joint review of the agency in-service binder, it was confirmed that there was no documentation of emergency preparedness education and training as per agency policy for the 2 employees cited in the findings.

It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. It is also required that the hospice conducts an additional exercise every two (2) years – opposite the year that a full-scale or functional exercise is conducted. This exercise may include but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise, a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. A review of the agency's Emergency Preparedness Plan (effective February 2023) and the agency's documented training and exercises for the years 2021 through 2023 revealed the agency did not ensure that the Emergency Plan was tested with one full-scale exercise per year alternating with a tabletop exercise/workshop or mock disaster drill on the opposite year. On February 25, 2023, the agency documented a facility-based functional exercise that included all staff members. The mock disaster drill centered around the scenario of flooding in and around the hospice's office. There was no documentation that the agency had enacted its Emergency Preparedness Plan in either 2021 or 2022. Additionally, there was no documentation that the agency conducted any additional exercises in 2021 or 2022. An interview with the Director of Clinical Services on 6/15/2023 confirmed that no additional documentation or testing had been performed in 2021 or 2022. No documentation was produced or provided prior to the end of the Site Visit. A review of the agency's Emergency Preparedness Plan (effective February 2023) and the agency's documented training and exercises for the years 2021 through 2023 revealed the agency did not ensure that the Emergency Plan was tested with one full-scale exercise per year alternating with a tabletop exercise/workshop or mock disaster drill on the opposite year. On February 25, 2023, the agency documented a facility-based functional exercise that included all staff members. The mock disaster drill centered around the scenario of flooding in and around the hospice's office. There was no documentation that the agency had enacted its Emergency Preparedness Plan in either 2021 or 2022. Additionally, there was no documentation that the agency conducted any additional exercises in 2021 or 2022. An interview with the Director of Clinical Services on 6/15/2023 confirmed that no additional documentation or testing had been performed in 2021 or 2022. No documentation was produced or provided prior to the end of the Site Visit.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by review of clinical records, documents, and interviews with the Director of Clinical Services/Volunteer Coordinator which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure of the hospice Interdisciplinary Group to ensure Hospice care and services provided to patients and families followed the individualized plan of care established by the hospice IDG in collaboration with the attending physician (53%) [HCPC.19.I/L543]; Failure of the Interdisciplinary Group to ensure patients' individualized written plans of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments (27%) [HCPC.21.I/L545]; and Failure to ensure the Interdisciplinary group documented review and revision of patients’ care plans as frequently as the patients’ condition required but no less frequently than every 15 days (20%) [HCPC.22.I/L552]. The cumulative effect of these deficiencies could negatively impact the organization’s ability to develop, update, and implement plans of care to ensure services are provided that will meet the care needs of patients.

It is required that a registered nurse member of the IDG ensures the implementation of the interdisciplinary plan of care and that hospice care and services provided to patients follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. 8 of 15 (53%) clinical records reviewed in which Chaplain services were accepted revealed the agency did not ensure that the chaplain provided patient visits at the frequencies ordered on the hospice plan of care (POC). Clinical Record 7: The patient elected the hospice benefit on 12/10/2022. In the Plan of Care Order 4/11/2023, the Chaplain visit frequency was ordered at once a month. A Chaplain/Counselor Visit was documented on 4/28/2023. The Plan of Care Orders dated 4/25/223, 5/9/2023, and 5/23/2023 continued to have the Chaplain visit frequency at once a month. There has been no Chaplain/Counselor Visit documented since 4/28/2023. There was no documented evidence in the clinical record that a Chaplain visit was provided in May 2023. Clinical Record 8: The patient elected the hospice benefit on 9/26/2022. In the Plan of Care Order 4/11/2023, the Chaplain visit frequency was ordered at once a month. A Chaplain/Counselor Visit was documented on 4/24/2023. The Plan of Care Orders dated 4/25/223, 5/9/2023, and 5/23/2023 continued to have the Chaplain visit frequency at once a month. There has been no Chaplain/Counselor Visit documented since 4/24/2023. There was no documented evidence in the clinical record that a Chaplain visit was provided in May 2023. Clinical Record 9: The patient elected the hospice benefit on 8/10/2022. In the Plan of Care Order 4/11/2023, the Chaplain visit frequency was ordered once a month. A Chaplain/Counselor Visit was documented on 4/23/2023. The Plan of Care Orders dated 4/25/2023 and 5/9/2023 continued to have the Chaplain visit frequency at once a month. There has been no Chaplain/Counselor Visit documented since 4/23/2023. There was no documented evidence in the clinical record that a Chaplain visit was provided in May 2023. Clinical Record 10: The patient elected the hospice benefit on 8/10/2022. In the Plan of Care Order 4/11/2023, the Chaplain frequency was ordered once a month. A Chaplain/Counselor Visit was documented on 4/24/2023. The Plan of Care Orders dated 4/25/2023 and 5/9/2023 continued to have the Chaplain visit frequency at once a month. There has been no Chaplain/Counselor Visit documented since 4/24/2023. There was no documented evidence in the clinical record that a Chaplain visit was provided in May 2023. Clinical Record 11: The patient elected the hospice benefit on 1/16/2023. In the Plan of Care Orders for 3/28/2023 and 4/11/2023, 4/25/2023, 5/9/223, 5/23/2023, and 6/6/2023 the Chaplain frequency was ordered at once a month. There was no documented evidence in the clinical record that Chaplain visits were provided in April 2023 or May 2023. Clinical Record 12: The patient elected the hospice benefit on 10/16/2020. In the Plan of Care Orders for 4/1/2023, 4/15/2023, 5/13/2023, 5/26/2023, and 6/10/2023 the Chaplain frequency was ordered once a month. There was a Chaplain/Counselor Visits documented 4/24/2023. There was no documented evidence in the clinical record that a Chaplain/Counselor was provided in May 2023. Clinical Record 13: The patient elected the hospice benefit on 10/16/2022. In the Plan of Care Order 4/15/2023, the Chaplain frequency was ordered once a month. A Chaplain/Counselor Visit was documented on 4/19/2023. The Plan of Care Orders dated 4/29/2023, 5/13/2023, and 5/26/2023 continued to have the Chaplain visit frequency at once a month. There has been no Chaplain/Counselor Visit documented since 4/19/2023. There was no documented evidence in the clinical record that a Chaplain visit was provided in May 2023. Clinical Record 14: The patient elected the hospice benefit on 11/8/2022. In the Plan of Care Order 4/15/2023, the Chaplain frequency was ordered once a month. A Chaplain/Counselor Visit was documented on 4/18/2023. The Plan of Care Orders dated 4/29/2023, 5/13/2023, and 5/26/2023 continued to have the Chaplain visit frequency at once a month. There has been no Chaplain/Counselor Visit documented since 4/18/2023. There was no documented evidence in the clinical record that a Chaplain visit was provided in May 2023. In interviews on 6/14/2023 and 6/15/2023, the Director of Clinical Services confirmed the missing Chaplain visits in clinical records 8, 9, 10, 11, 12, 13, 14, and 15, and no further documentation was produced prior to the end of the Site Visit.

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. 3 of 15 (27%) clinical records reviewed revealed the agency did not ensure patients' written plans of care included updated planned interventions or goals based on problems identified in the updated assessments. Clinical Record 7: The patient elected the hospice benefit on 12/10/2022. In the RN Recertification Visit dated 4/25/2023, the nurse documented that the patient was dyspneic with moderate exertion. During the Chaplain/Counselor Visit dated 4/28/2023, it was noted that the patient had to pause during conversation to rest and catch their breath before they could continue to converse. In the RN Skilled Nursing Visit notes on 5/17/2023, 5/23/2023, and 5/30/2023, the nurse documented the patient was short of breath with minimal exertion or agitation. On 5/2/2023, 5/9/2023, 5/17/2023, and 5/23/2023, the nurse documented that the patient's symptoms of multiple sclerosis, including muscle tension and spasm, were well managed with the patient's medication regimen. In the Plan of Care Orders dated 4/25/2023, 5/9/2023, and 5/23/2023, the only medication listed was Celecoxib 200mg daily for pain. The identified problem list included in the Interdisciplinary Group (IDG) Meeting updates dated 4/25/2023, 5/9/2023, and 5/23/2023 included: risk for altered comfort/pain (the effective date of 5/9/2023), the risk for altered nutrition (the effective date of 5/9/2023), spiritual practices (the effective date of 3/30/2023), to listen to patient review (the effective date of 3/22/2023), spiritual disruption/coping (the effective date of 12/29/2022), and education on death/dying (the effective date of 10/28/2022). There were no identified problems, interventions, or goals in the patient's plan of care to address newly identified issues of shortness of breath or muscle spasm and tension secondary to the diagnosis of multiple sclerosis. The plan of care was not updated to include documentation of the new findings. Clinical Record 8: The patient elected the hospice benefit on 9/26/2022. In the PRN RN Skilled Nursing Visit on 4/27/23, the nurse collected a specimen of urine because there was a suspected urinary tract infection (UTI). A physician order dated 4/27/2023 for a urine specimen culture and sensitivity was documented. In the physician's Certification of Terminal Illness dated 4/29/2023, the hospice physician documented, "... has had multiple UTI and now family members concerned that patient has been having vaginal bleeding. We ordered a urine culture which was negative for UTI or blood. Her vaginal exam shows blood that is dark with a fetid odor. Vaginal bleeding: offered a workup since differential diagnosis includes pelvic mass, cervicouterine cancer ... I had a meeting with family members, and they decided not to pursue workup ..." In the RN Skilled Nursing Visit on 5/4/2023, the nurse documented that the patient has been demonstrating more insomnia, wandering back and forth aimlessly ...hallucinations. The documentation stated, "RN contacted Dr... who gave new order for lorazepam 0.5mg 1 tablet by mouth every 4-6 hours as needed for anxiety. RN provided education on medication regimen and instructed on following physician orders." During the RN Skilled Nursing Visit on 5/30/2023, the nurse documented an oxygen saturation of 85% on room air and oxygen was placed on the patient at 2 liters per minute by nasal cannula. The patient’s problem list included in the Interdisciplinary Group (IDG) Meeting updates dated 4/11/2023 and 5/9/2023 (IDG meeting documentation was missing for dates 4/25/2023 and 5/23/2023) included: disruption of spiritual practices (the effective date of 9/27/2022), to provide emotional support (the effective date of 9/27/2022), the risk for aspiration (the effective date of 10/4/2022), incontinence (the effective date of 10/4/2022), the risk for alteration in skin integrity (the effective date of 10/18/2022), and decreased nutrition (the effective date of 3/21/2023). The findings from the updated comprehensive assessments were not identified in the patient's written plan of care updates. No newly identified problems, interventions or goals were included to address the patient's vaginal bleeding/suspected pelvic tumor, new onset of anxiety/agitation/insomnia, or the need for oxygen. Clinical Record 10: The patient elected the hospice benefit on 8/10/2022. During the RN Skilled Nursing Visit on 5/2/2023, it was documented that the patient had tolerated 4 cans per day of Jevity 1.2 that were fed by bolus. The nurse also documented that the son offered water flushes with feedings and medications. On the RN Recertification Visit on 5/23/2023, the nurse documented that the patient received PEG tube feedings due to dysphagia. The documentation stated, "Son provides feedings of Jevity 1.2, which have been reduced to 4 cans per day with better tolerance by the patient. Son checks for residuals, and only trace residuals are reported." The problem list for Interdisciplinary Group Meeting updates for the dates 4/11/2023 - 5/23/2023 included the problem "Pt fed via peg" and the description included "Jevity 1.2, 6 cans/day and 1.5 water daily." There was a physician order dated 6/3/2022 to give the patient 6 cans per day of Jevity 1.2. There was no updated physician order to decrease the amount of formula given from 6 cans a day to 4 cans a day. There was also no order specifying whether the feedings would be done by feeding pump or by bolus feeding, no order for water boluses, no order to check residuals, and no parameters for residuals. The RN Skilled Nursing Visit dated 4/13/2023 documented a 20 Fr 30cc balloon Foley catheter "last changed 3/15/2023." There was a physician order on 6/3/2022: Foley Catheter, may insert 16Fr 10-30cc balloon catheter PRN s/s retention or patient comfort, change PRN.” Then on 6/21/2022, a physician's order indicated a change from 16 Fr to 18 Fr Foley due to leaking around the 16 Fr. Per RN documentation in RN Skilled Nursing Visit on 4/13/2023, the patient has a 20Fr foley catheter in place. There was no order found for a 20 Fr Foley. In a PRN RN Skilled Nursing Visit note on 4/13/2023, the nurse documented, "son states pt is starting with S&S of anxiety. Usually, patient has UTI's when she has anxiety..." " Bactrim DS 800/160: 1 PO BID UTI; Morphine sulfate 20mg/ml: 0.5 ml q 6 hours PRN pain" was documented in a physician's order dated 4/13/2023. There was a "high risk for UTI" problem identified, but no indication that the patient had an active, treated urinary tract infection on 4/13/2023. There was a physician order for 4/13/2023 for Morphine 20mg/ml: 0.5cc every 6 hours as needed for pain. There was no problem related to pain identified in the patient's problem list from 4/25/2022 - 5/23/2023. The plan of care updates from 4/11/2023 to 5/23/2023 did not address the specifics of the PEG/G-tube feedings or any problem identified with feeding intolerance requiring the decrease from 6 cans a day to 4 cans a day. There was a discrepancy between the Foley catheter orders and what the nurse documented that the patient actually had inserted. There was no active UTI problem addressed with appropriate antibiotic therapy interventions. And lastly, pain was identified on 4/13/2023 and the physician ordered Morphine. There was no identified problem, interventions or goals related to pain in the patient's plan of care. No newly identified problems, interventions or goals were included to address the patient's vaginal bleeding/suspected pelvic tumor, new onset of anxiety/agitation/insomnia, or the need for oxygen. In an interview on 6/14/2023 and 6/15/2023 during a review of clinical record findings, the Director of Clinical Services provided no explanation of why plans of care did not include the updated findings from the comprehensive assessments. No documentation was produced before the end of the site visit to address these issues with the care plans for records 8, 9, and 11.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. 3 of 15 (20%) clinical records reviewed revealed the agency did not ensure the interdisciplinary group (IDG) met at least every fifteen days to review and revise patients' individualized plans of care. Agency Policy "Interdisciplinary Group Meetings" (2-050) with the date of January 2023 stated in part, "An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes..." Clinical Record 7: The patient elected the hospice benefit on 12/10/2022. The Interdisciplinary Group (IDG) Meetings were documented on 4/11/2023, 4/25/2023, and 5/9/2023. There was no documented IDG Meeting on 5/23/2023 or 6/6/2023 and no documented evidence in the clinical record that the IDG reviewed, revised or documented the patient’s individualized plan of care. Clinical Record 8: The patient elected the hospice benefit on 9/26/2022. The Interdisciplinary Group (IDG) Meetings were documented on 4/11/2023 and 5/9/2023. There were no documented IDG Meeting on 4/25/2023, 5/23/2023, 6/6/2023 and no documented evidence in the clinical record that the IDG reviewed, revised or documented the patient’s individualized plan of care. Clinical Record 10: The patient elected the hospice benefit on 8/10/2022. The Interdisciplinary Group (IDG) Meetings were documented on 4/11/2023, 5/9/2023, and 5/23/2023. There were no documented IDG Meetings on 4/25/2023 or 6/6/2023 and no documented evidence in the clinical record that the IDG reviewed, revised or documented the patient’s individualized plan of care. During interviews on 6/14/2023 and 6/15/2023, the Director of Clinical Services confirmed that there was missing Interdisciplinary Group (IDG) Meeting documentation for clinical records 8, 9, and 11. No additional documentation was produced prior to the end of the site visit.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: Reflects the complexity of the hospice and services; Involves all hospice services, including those provided under contract; Addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; Focuses on indicators related to improved palliative outcomes; Includes investigation and analysis of sentinel and adverse events; Includes defined data detail and frequency of collection, and approves such; Has evidence of action taken that results in improvement in hospice performance; and, Is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by Quality Improvement document review and interview with the Director of Clinical Services which revealed issues with the organization's Quality Assessment Performance Improvement (QAPI) program in the following areas: Failure to demonstrate measurable improvement in quality indicators related to improvement of palliative outcomes and hospice services [HQPI.3.1/L561]; and Failure to take action to improve performance, measure success, and track performance to ensure that improvements were sustained [HQPI.8.I/L570]. The cumulative effect of these deficiencies could impact the organization's ability to assess the care and services provided by hospice and ensure the provision of high-quality care and services.

It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by document review and interview. The agency did not ensure measurable improvement among quality indicators related to improved palliative outcomes and hospice services. A review of the agency's QAPI documentation that included QAPI Meeting Minutes dated 3/16/2023, quality indicators to include an infection log for 2023 (no infections documented), satisfaction surveys (blank), HIS measures, incident logs (7 falls), complaints/grievances (blank), chart audits (4 audits from 2/2023 only), on-call logs (blank), re-hospitalization log (blank), and QAPI performance improvement projects revealed that the agency has no documentation showing data collection or audits in order to track outcomes or progress. The Volunteer Program Performance Improvement Project (PIP) was initiated on 3/16/2023 to address volunteer hours, recruitment and retention efforts, and documentation. The Volunteer PIP assigns the Director of Clinical Services/Alternate Administrator to oversee the PIP. The PIP states the "Administrator will audit volunteer activity and hours monthly...all audits will be reported to the QAPI Committee monthly for review and further recommendation." There was no audit or reporting data documented since the initiation of the PIP in order to track the progress of the improvement after education and interventions were implemented, so therefore the QAPI program was unable to demonstrate any improvement. The Plan of Care Performance Improvement Project (PIP) was initiated on 3/23/2023 to address timely and complete updates to patients' plans of care. The Plan of Care PIP assigns the Director of Clinical Services/Alternate Administrator to oversee audits of documentation. and includes "... will audit all completed documentation with a focus on timeframes per agency policy." There was no audit or reporting data documented since the initiation of the PIP in order to track the progress of the improvement after education and interventions were implemented, so therefore the QAPI program was unable to demonstrate any improvement. There was no documented evidence of quality indicators or PIP related to palliative outcomes. An interview with the Director of Clinical Services on 6/15/2023 confirmed that no audit data was available, and no documentation could be produced before the end of the Site Visit that demonstrated evidence of improvement in outcomes or hospice services. A review of the agency's QAPI documentation that included QAPI Meeting Minutes dated 3/16/2023, quality indicators to include an infection log for 2023 (no infections documented), satisfaction surveys (blank), HIS measures, incident logs (7 falls), complaints/grievances (blank), chart audits (4 audits from 2/2023 only), on-call logs (blank), re-hospitalization log (blank), and QAPI performance improvement projects revealed that the agency has no documentation showing data collection or audits in order to track outcomes or progress. The Volunteer Program Performance Improvement Project (PIP) was initiated on 3/16/2023 to address volunteer hours, recruitment and retention efforts, and documentation. The Volunteer PIP assigns the Director of Clinical Services/Alternate Administrator to oversee the PIP. The PIP states the "Administrator will audit volunteer activity and hours monthly...all audits will be reported to the QAPI Committee monthly for review and further recommendation." The Plan of Care Performance Improvement Project (PIP) was initiated on 3/23/2023 to address timely and complete updates to patients' plans of care. The Plan of Care PIP assigns the Director of Clinical Services/Alternate Administrator to oversee audits of documentation. and includes "... will audit all completed documentation with a focus on timeframes per agency policy." An interview with the Director of Clinical Services/Alternate Administrator on 6/15/2023 confirmed that no audit data was available and no documentation could be produced before the end of the Site Visit to demonstrate active QAPI oversight for program indicators. The QAPI PIPs were initiated in March of 2023. There was no audit or reporting data documented since the initiation of the PIPS in order to track the progress of the improvement after education and interventions were implemented, so therefore the QAPI program was unable to demonstrate any improvement.

It is required that the hospice takes action to improve performance, assesses the success of the action after implementing it, and tracks ongoing results to ensure improvement is sustained. This standard was not met as evidenced by document review and interview. A review of the agency's QAPI documentation that included QAPI Meeting Minutes dated 3/16/2023, quality indicators to include an infection log for 2023 (no infections documented), satisfaction surveys (blank), HIS measures, incident logs (7 falls), complaints/grievances (blank), chart audits (4 audits from 2/2023 only), on-call logs (blank), re-hospitalization log (blank), and QAPI performance improvement projects revealed that the agency had no documentation showing data collection to identify problems or audits to track outcomes or progress. The Volunteer Program Performance Improvement Project (PIP) was initiated on 3/16/2023 to address volunteer hours, recruitment and retention efforts, and documentation. The Volunteer PIP assigned the Director of Clinical Services/Alternate Administrator to oversee the PIP. The PIP states the "Administrator will audit volunteer activity and hours monthly...all audits will be reported to the QAPI Committee monthly for review and further recommendation." There was no documented evidence that the Volunteer PIP was followed after it was initiated on 3/16/2023. The Plan of Care Performance Improvement Project (PIP) was initiated on 3/23/2023 to address timely and complete updates to patients' plans of care. The Plan of Care PIP assigns the Director of Clinical Services/Alternate Administrator to oversee audits of documentation. and includes "... will audit all completed documentation with a focus on timeframes per agency policy." There was no documented evidence of audit data since the initiation of this PIPs in order to assess the success of improvement activities implemented with the PIP. An interview with the Director of Clinical Services on 6/15/2023 confirmed that no audit data was available, and no documentation could be produced before the end of the Site Visit to demonstrate active QAPI oversight for program indicators. A review of the agency's QAPI documentation that included QAPI Meeting Minutes dated 3/16/2023, quality indicators to include an infection log for 2023 (no infections documented), satisfaction surveys (blank), HIS measures, incident logs (7 falls), complaints/grievances (blank), chart audits (4 audits from 2/2023 only), on-call logs (blank), re-hospitalization log (blank), and QAPI performance improvement projects revealed that the agency has no documentation showing data collection or audits in order to track outcomes or progress. The Volunteer Program Performance Improvement Project (PIP) was initiated on 3/16/2023 to address volunteer hours, recruitment and retention efforts, and documentation. The Volunteer PIP assigns the Director of Clinical Services/Alternate Administrator to oversee the PIP. The PIP states the "Administrator will audit volunteer activity and hours monthly...all audits will be reported to the QAPI Committee monthly for review and further recommendation." The Plan of Care Performance Improvement Project (PIP) was initiated on 3/23/2023 to address timely and complete updates to patients' plans of care. The Plan of Care PIP assigns the Director of Clinical Services/Alternate Administrator to oversee audits of documentation. and includes "... will audit all completed documentation with a focus on timeframes per agency policy." An interview with the Director of Clinical Services/Alternate Administrator on 6/15/2023 confirmed that no audit data was available and no documentation could be produced before the end of the Site Visit to demonstrate active QAPI oversight for program indicators. The Volunteer Program PIPS contained a plan for volunteer hours, recruitment, and retention documentation, auditing, and reporting frequency and amount. The PIP plan was not followed after its initiation on 3/16/2023. The Plan of Care PIP also contained a plan for ongoing audits of clinical records, including frequency of audits and quantity of charts to be audited with reporting requirements. The PIPs were initiated in March of 2023. There was no audit data documented since the initiation of the PIPS in order to assess the success of the improvement activities implemented with the PIPS.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. 1 of 3 (33%) home visit observations revealed the agency did not ensure that clinical staff followed the agency's policy that addressed hand hygiene in patients' homes. Agency Policy "Hand Hygiene" (9-009), dated January 2023, stated in part, "Hand decontamination using an alcohol-based hand rub should be performed ...After contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient)." Home Visit 2: While observing the nurse on Home Visit #2 (Clinical Record 14) on 6/14/2023, the agency's hand hygiene policy was not followed. After obtaining the patient's blood pressure and pulse, the nurse did not clean their hands with the alcohol sanitizer before continuing the visit or going back into the "clean" section of the bag to retrieve an item. In an interview on 6/15/2023, the Director of Clinical Services confirmed the RN remembered that after assessing the patient's vital signs, an alcohol-based sanitizer was not used to decontaminate her hands after patient contact.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. 4 of 8 (50%) personnel records reviewed revealed the agency did not ensure the hospice provided infection control education in accordance with agency policy. The retired agency policy "Agency Inservices" (HR.13), with the revised date 1/1/2020 stated in part, "...the agency ...will provide inservices annually and will mandate attendance as appropriate to job classification ... Infection Control Program, Exposure Control Airborne/Blood Born Pathogen Program." The current agency policy "Personnel Development" (1-011) with the effective date of January 2023 stated in part, "...requires that each hospice personnel complete a minimum of the following programs each year...Standard Precautions and Infection Control." Personnel Record 1: The Administrator with a date of hire of 3/19/2019 had documentation in the personnel record that the agency provided infection control teaching upon hire. There was no documented evidence of infection control in-service training for 2021 or 2022. Personnel Record 4: The Social Worker with a date of hire of 6/15/2021 had documentation in the personnel record that the agency provided infection control teaching upon hire. There was no documented evidence of infection control in-service training for 2022. Personnel Record 6: The Hospice Aide with a date of hire of 5/6/2021 had documentation in the personnel record that the agency provided infection control teaching upon hire. There was no documented evidence of infection control in-service training for 2022. Personnel Record 8: The Chaplain/Bereavement Coordinator with a date of hire of 3/30/2020 had documentation in the personnel record that the agency provided infection control teaching upon hire. There was no documented evidence of infection control in-service training for 2021 or 2022. In an interview and further review of the in-service binder on 6/15/2023, the Director of Clinical Services confirmed there was no documentation of required infection control in-services for 2021 and 2022 for personnel files reviewed during the site visit.

It is required that licensed professionals participate in hospice-sponsored in-service training. This standard was not met as evidenced by document review, interview and personnel record review. 4 of 7 (58%) personnel files reviewed of licensed professionals revealed the agency did not ensure that the required hospice in-services were completed and documented. Agency Policy "Personnel Development" (1-011) with the date of January 2023 stated in part, "... requires that each hospice personnel complete a minimum of the following programs each year... These programs must include standard precautions and infection control, safety programs, including environmental safety, body mechanics, emergency preparedness, corporate compliance and standards of conduct, and HIPAA." The previous agency policy "Agency Inservices" (HR. 13) dated 1/1/2020 stated in part that the "...agency ... will provide the following inservices annually and mandate attendance...infection control ... Emergency Preparedness." Personnel Record 1: The personnel file of the Administrator, with a date of hire (DOH) 3/19/2019 did not include evidence of required agency in-service documentation for 2021 or 2022. Personnel Record 4: The personnel file of the Social Worker (MSW) with a DOH 6/15/2021 did not include evidence of required agency in-service documentation for 2022. Personnel Record 5: The personnel file for the Chaplain with a DOH 10/29/2021 did not include evidence of required agency in-service documentation for 2022. Personnel Record 8: The Chaplain/Bereavement Coordinator with a DOH 3/30/2020 did not include evidence of required agency in-service documentation for 2021 or 2022. In an interview with the Director of Clinical Services (DCS)/Alternate Administrator on 6/15/2023 and a review of the missing in-service documentation in four of the personnel files, an education binder was produced and reviewed. A joint review of the education binder with the DCS failed to include the required agency in-service documentation for 2021 and/or 2022 for Personnel Files Reviewed (1, 4, 5, 8).

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 3 of 11 (27%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure that the registered nurse included all necessary instructions in the Aide Plan of Care to ensure appropriate and safe care of the patient during hospice aide visits. The State Board of Nursing "Delegation Principles" included documentation that when the RN delegates a task to unlicensed personnel, those instructions should include, "Situation-specific communication includes...specific activities to be performed and client-specific instruction and limitation." Clinical Record 10: The patient elected the hospice benefit on 8/10/2022. The Plan of Care Orders dated 3/28/2023, 4/11/2023, 4/25/2023, 5/9/2023, and 5/23/2023 ordered the Aide frequency five times a week. A physician order dated 6/3/2022 stated a Foley catheter was to be placed in the patient. Also included were orders for G-tube feedings of Jevity 1.2: 6 cans per day. The 5/2/2023 RN Skilled Nursing Visit note stated, "He reports that patient has tolerated her feedings of 4 cans per day given via bolus feed to gravity - 1 can for breakfast, 1 can for lunch and 2 cans for dinner. He offers water flushes with feedings and medications." The Aide Plan of Care dated 4/2/2023 did not include any information, instruction, or interventions for the Hospice Aide in the care and handling of the Foley catheter or the PEG/G-tube. There were no documented updates to the Aide Plan of Care since 4/2/2023. Clinical Record 11: The patient elected the hospice benefit on 1/16/2023. The Plan of Care Orders dated 4/11/2023, 4/25/2023, 5/9/2023, 5/23/2023, and 6/6/2023 ordered the Aide visit frequency five times a week. In the Plan of Care Order dated 4/11/2023, the medication list included 5 liters of continuous oxygen per nasal cannula (start date 4/11/2023). The identified problem of "Oxygen Need" had the description of 5-10 liters per minute of oxygen per nasal cannula. The RN Skilled Nursing Visit note dated 4/14/2023 stated the patient was receiving 8 liters of oxygen continuous per nasal cannula. The RN Skilled Nursing Visit note dated 4/25/2023 stated the patient had changed from the previous assessment of 8 liters of oxygen per nasal cannula to 3 liters per minute per non-rebreather mask. The Aide Plan of Care dated 4/16/2023 did not include information, instruction, or intervention for the Hospice Aide regarding whether the patient's oxygen may be removed for care. There is a box checked for dyspnea and oxygen on the Aide Plan of Care, but no settings or how to handle the oxygen during care. There were no documented updates to the Aide Plan of Care since 4/16/2023. Clinical Record 5: The patient elected the hospice benefit on 12/9/2022. The Plan of Care Orders beginning 12/9/2022 and continuing through 3/14/2023, ordered the Aide visit frequency five times a week. The Physician's Certification of Terminal Illness dated 12/9/2022 stated, "he requires oxygen per nasal cannula at 4 liters per minute." The RN Skilled Nursing Visit notes on 2/6/2023, 2/13/2023, 2/20/2023, and 2/27/2023, and the RN Recertification Visit 3/6/2023 all documented that the patient was wearing oxygen at 4 liters per minute per nasal cannula continuously during the day and that his wife stated he takes the oxygen off at night to sleep. As of 3/13/2023, during the RN Skilled Nursing Visit, the patient's wife stated that he was also wearing oxygen at night. The documentation on the 3/13/2023 visit also stated the patient had become bedbound. The Aide Plans of Care for 12/9/2022 and 3/9/2023 (the only two Aide Plans of Care documented) included a box checked for dyspnea and one for oxygen use. The RN did not provide instructions on whether the oxygen could be removed for care. The Aide was instructed to provide a "complete shower" every visit. On 3/13/2023, the nurse documented that the patient had become bedbound. There was no update to the Aide Plan of Care which continued to state a "complete shower" every visit. A shower was marked as completed by the aide on 3/13/2023 and 3/14/2023. There was no documented evidence that the Aide communicated to the RN a need to change the Aide's Plan of Care from shower to bed bath. On 3/15/2023, the day of death, the Aide marked the "complete shower" as "refused." In an interview on 6/25/2023, the Director of Clinical Services confirmed that in clinical records 5, 11, and 12, the patients’ RN did not include appropriate instructions for the Hospice Aide for the management of the oxygen or PEG/G-tube.

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. 4 of 11 (36%) clinical records reviewed revealed the agency did not ensure that the hospice aide was supervised every fourteen days by the RN. Clinical Record 7: The patient elected the hospice benefit on 12/10/2022. The Interdisciplinary Plan of Care Order dated 4/11/2023 ordered Aide visits five times a week. An Aide Supervisory Visits was documented on 5/2/23. There were no supervisory visits documented through 6/9/23. Clinical Record 8: The patient elected the hospice benefit on 9/26/2022. The Interdisciplinary Plan of Care Order dated 4/11/2023 ordered Aide visits twice a week. There was documentation of an Aide Supervisory Visit dated 5/17/2023. There were no supervisory visits documented through 6/8/2023. Clinical Record 9: The patient elected the hospice benefit on 8/10/2022. The Interdisciplinary Plan of Care Order dated 4/11/2023 ordered Aide visits three times a week. There was documentation of an Aide Supervisory Visit dated 5/17/2023. There were no supervisory visits documented through 6/9/2023. Clinical Record 10: The patient elected the hospice benefit on 8/10/2022. The Interdisciplinary Plan of Care Order 4/11/2023 ordered Aide visits five times a week. There was documentation of Aide Supervisory Visits dated 5/17/2023 and 5/30/2023, 15 days outstanding. In interviews on 6/14/23 and 6/15/23, the Alternate Administrator/Director of Clinical Services confirmed that Hospice Aide supervision was not documented in the clinical records at least every fourteen days, and no further documentation could be produced for these patients by the end of the site visit.

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes The volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality, and protection of the patient’s and family’s right, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 1 (100%) volunteer personnel record reviewed, revealed the agency did not document volunteer orientation or training. Agency Policy "Personnel Record Contents" (Policy No. 1-006) with the effective date of January 2023, stated on page six that the Volunteer's personnel record should contain an orientation checklist. Then in the policy "Orientation" (1-010) dated January 2023 on page 3 stated in part, "In addition, the orientation for hospice personnel and volunteers, as appropriate to their responsibilities and prior education and experience will include the following topics: concepts of death and dying, psychological and spiritual issues related to death and dying, Communication skills with dying patients and/or families/caregivers, pain and symptom management in palliative care, concepts of stress management for hospice personnel involved in caring for dying patients, handling of a death in the home." Additionally, the policy includes that "An Orientation Checklist (See “Personnel Orientation Checklist” Addendum 1-010. A.) will be completed for each new staff. New staff will sign and date when their orientation has been completed. The Preceptor/assigned Supervisor will sign and date when the new staff have completed all required activities." "10. All assigned staff members, students or volunteers will be oriented to their roles and responsibilities and to the patient needs when changes in patient assignment occur. The following will be included as appropriate to care responsibilities..." Personnel Record 7: The Volunteer with the hire date of 6/9/2022, had no documented evidence of completion of Volunteer Orientation or Training in the personnel file upon review on 6/15/2023. Upon joint review of the volunteer's personnel file with the Director of Clinical Services, who is also acting as the Volunteer Coordinator, it was confirmed that there no documentation of Volunteer Orientation within the Volunteer's personnel file. No further documentation was able to be produced by the end of the site visit.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by review of documents, personnel records, clinical records, and interviews with the Director of Clinical Services, Medical Director and Associate Medical Director, which revealed issues in the way the hospice organizes, manages and administers its resources to provide hospice care and services in the following areas: Failure of the parent organization to ensure that supervision was shared with the Alternate Delivery Site (ADS) [HSLG.17.I/L657]; Failure of the parent organization to monitor and manage services provided at the ADS [HSLG.18.I/L660]; and Failure to ensure that patients' individualized emergency plans included information to facilitate patient evacuation and transportation [HSEP.3.D/E19]. The cumulative effect and scope of these deficiencies could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS), shares administration, supervision, and services with the hospice issued the certification number. This standard was not met as evidenced by record review, document review and interview. 5 of 5 (100%) clinical records reviewed revealed the parent organization did not ensure that supervision was shared with the ADS. A review of the hospice's current state licensure revealed that the agency has an Alternative Delivery Site (ADS) with an effective date of 10/9/2022. A review of the hospice's active census revealed three patients assigned to the parent location and five patients assigned to the ADS, located 540 miles (approximately seven hours) from the patient location. Clinical Record 8: The patient elected the hospice benefit on 12/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical Record 9: The patient elected the hospice benefit on 9/26/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical Record 10: The patient elected the hospice benefit on 8/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical Record 11: The patient elected the hospice benefit on 8/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical Record 12: The patient elected the hospice benefit on 1/16/2023. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. The Hospice Medical Director was interviewed on 6/15/2023 and stated that he had never attended an Interdisciplinary Group (IDG) Meeting at the ADS in person, by phone, or by video conference. He did provide that he and the Associate Medical Director would review patients occasionally at admission or during recertification to discuss if the patient met or continued to qualify for the hospice benefit. He was unable to provide any information about the official supervision of the ADS or the Associate Medical Director. The Associate Medical Director was also interviewed on 6/15/2023. During the interview, he stated and confirmed that he and the Medical Director do occasionally speak by phone about specific patients and that he can reach out by phone to the Medical Director as needed. But when asked about how the Medical Director provided supervision, he stated, "I thought I was the Medical Director of the ADS." The Director of Clinical Services was interviewed on 6/15/2023 and stated, "I visit the ADS once a month, but I don't have anything documented." There was no documentation produced by the end of the Site Visit that demonstrated that the parent and ADS site shared administration or supervision by the Hospice Medical Director or the Director of Clinical Services. A review of the hospice's current state licensure revealed that the agency has an Alternative Delivery Site (ADS) with an effective date of 10/9/2022. Then a review of the hospice's active census revealed three patients assigned to the parent location and five patients assigned to the ADS, located 540 miles (approximately seven hours) from the patient location. Clinical record 8: The patient elected the hospice benefit on 12/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical record 9: The patient elected the hospice benefit on 9/26/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical record 10: The patient elected the hospice benefit on 8/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical record 11: The patient elected the hospice benefit on 8/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical record 12: The patient elected the hospice benefit on 1/16/2023. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. The Hospice Medical Director was interviewed on 6/15/2023 and stated that he had never attended an Interdisciplinary Group (IDG) Meeting at the ADS in person, by phone, or by video conference. He did provide that he and the Associate Medical Director would review patients occasionally at admission or during recertification to discuss if the patient met or continued to qualify for the hospice benefit. He was unable to provide any information about the official supervision of the ADS or the Associate Medical Director. The Associate Medical Director was also interviewed on 6/15/2023. During the interview, he stated and confirmed that he and the Medical Director do occasionally speak by phone about specific patients and that he can reach out by phone to the Medical Director as needed. But when asked about how the Medical Director provided supervision, he stated, "I thought I was the Medical Director of the ADS." The Director of Clinical Services/Alternate Administrator was interviewed on 6/15/2023 and stated, "I visit the ADS once a month, but I don't have anything documented." There was no documentation that was produced by the end of the Site Visit that demonstrated that the parent and ADS site shared administration or supervision by the Hospice Medical Director or the Director of Clinical Services.

It is required that a hospice continually monitors and manages all services provided at each of its multiple locations to ensure services are delivered in a safe and effective manner, each patient and family receives the necessary care and services outlined in the plan of care, and the scope of care and services is the same as offered directly or under contract at the location with the certification number. This standard was not met as evidenced by clinical record review, document review and interview. A review of the hospice's current state licensure revealed that the agency has an Alternative Delivery Site (ADS) with an effective date of 10/9/2022. Then a review of the hospice's active census revealed three patients assigned to the parent location and five patients assigned to the ADS, located 540 miles (approximately seven hours) from the patient location. There was no evidence presented during the site visit that the parent location monitored any services delivered by employees or contract staff at the ADS. There was no documented evidence of clinical record reviews or contract reviews conducted at the ADS. There was no documented evidence of visits to the ADS and no documentation of participation by the Director of Nursing (DON) or the Medical Director of oversight or participation in any of the ADS IDG meetings. There was no evidence of any QAPI documentation since March 2023. There was no evidence of supervisory visits of any field staff or the new Assistant DON who started work in April 2023. There was no evidence that the DON or Medical Director had visited the ADS. There was no documented evidence of agency-wide meetings or in-service training. The Hospice Medical Director was interviewed on 6/15/2023 and stated that he had never attended an Interdisciplinary Group (IDG) Meeting at the ADS in person, by phone, or by video conference. He stated that he and the Associate Medical Director would review patients occasionally at admission or during recertification to discuss if the patient met or continued to qualify for the hospice benefit. He was unable to provide any information about the official supervision of the ADS or the Associate Medical Director. The Associate Medical Director was also interviewed on 6/15/2023. During the interview, he stated and confirmed that he and the Medical Director did occasionally speak by phone about specific patients on occasion and that he can reach out by phone to the Medical Director as needed. But when asked about how the Medical Director provided supervision, he stated, "I thought I was the Medical Director of the ADS." The Director of Clinical Services/Alternate Administrator was interviewed on 6/15/2023 and stated, "I visit the ADS once a month, but I don't have anything documented." There was no documentation produced by the end of the Site Visit that demonstrated management and oversight of the ADS office by the parent office or by the Director of Clinical Services. After the interview of the Hospice Medical Director and the Associate Medical Director on 6/15/2023, there was no interview evidence that supported active involvement with the ADS by the Hospice Medical Director. There was no documentation provided by the end of the site visit. A review of the hospice's current state licensure revealed that the agency has an Alternative Delivery Site (ADS) with an effective date of 10/9/2022. Then a review of the hospice's active census revealed three patients assigned to the parent location and five patients assigned to the ADS, located 540 miles (approximately seven hours) from the patient location. Clinical record 8: The patient elected the hospice benefit on 12/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical record 9: The patient elected the hospice benefit on 9/26/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical record 10: The patient elected the hospice benefit on 8/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical record 11: The patient elected the hospice benefit on 8/10/2022. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. Clinical record 12: The patient elected the hospice benefit on 1/16/2023. A clinical record review revealed the patient was assigned to the ADS and receiving hospice care and services. There was no documented evidence the ADS shares supervision with the parent site. The Hospice Medical Director was interviewed on 6/15/2023 and stated that he had never attended an Interdisciplinary Group (IDG) Meeting at the ADS in person, by phone, or by video conference. He did provide that he and the Associate Medical Director would review patients occasionally at admission or during recertification to discuss if the patient met or continued to qualify for the hospice benefit. He was unable to provide any information about the official supervision of the ADS or the Associate Medical Director. The Associate Medical Director was also interviewed on 6/15/2023. During the interview, he stated and confirmed that he and the Medical Director do occasionally speak by phone about specific patients on occasion and that he can reach out by phone to the Medical Director as needed. But when asked about how the Medical Director provided supervision, he stated, "I thought I was the Medical Director of the ADS." The Director of Clinical Services/Alternate Administrator was interviewed on 6/15/2023 and stated, "I visit the ADS once a month, but I don't have anything documented." There was no documentation produced by the end of the Site Visit that demonstrated management and oversight of the ADS office by the parent office or by the Director of Clinical Services. After the interview of the Hospice Medical Director and the Associate Medical Director on 6/15/2023, there was no interview evidence that supported active supervision of the ADS by the Hospice Medical Director. There was no documentation provided by the end of the Site Visit.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 7 (14%) personnel records reviewed in which staff provided patient care revealed the agency did not ensure that the staff member's competence was assessed and documented during the orientation period. Agency policy, "Scope of the Program/Process Methodology" (3-001) with the date of January 2023 stated in part, "...The preceptor/supervisor will observe and deem proficient the indicated skills and core competencies... Hospice personnel will not provide the care or service independently until satisfactory completion of required skills competency." Personnel Record 7: The Volunteer with a date of hire of 6/22/222 did not have a Volunteer Competency Assessment performed or documented for the initial orientation period. In an interview on 6/15/2023 with the Director of Clinical Services, who also served as the Volunteer Coordinator, no documentation was found or produced that showed Staff 7 had a volunteer competency performed during the orientation period.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by record review and interviews with the Medical Director and Associate Medical Director which revealed a failure to assume responsibility for the palliation and management of patients' terminal illness and related conditions. During an interview on 6/15/2023, the Hospice Medical Director stated that he had never attended an Interdisciplinary Group (IDG) Meeting at the ADS in person, by phone, or by video conference. The Medical Director stated that he and the Associate Medical Director would review patients occasionally at admission or during recertification to discuss if the patient met or continued to qualify for the hospice benefit. The Medical Director was unable to provide information about the supervision of the Alternate Delivery Site (ADS) or the Associate Medical Director. In addition, during an interview on 6/15/2023, the Associate Medical Director confirmed that he and the Medical Director occasionally spoke by phone about specific patients and contacted the Medical Director by phone as needed. When asked about the Medical Director providing supervision, he stated, "I thought I was the Medical Director of the ADS." The cumulative effect of these deficiencies could result in the physician providing oversight of the patients, not having a full understanding of their needs and/or potential changes in their condition.

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. 1 of 2 (50%) clinical record reviewed in which a patient was transferred to a Medicare/Medicaid certified facility revealed the agency did not ensure that a copy of the discharge summary was forwarded to the receiving hospice. Clinical Record 3: The patient elected the hospice benefit on 12/21/2022. A physician order dated 2/3/2023 stated the patient would be discharged from hospice services per patient or family request. The patient was transferred to another hospice. A discharge summary was located in the Patient Communication section of the medical record and stated that "patient/caregiver request transfer." At the bottom of the summary, it stated, "... a copy of the discharge summary will be sent to the physician..." There was no documented evidence that a copy of the discharge summary was provided to the receiving hospice. In an interview and review of missing documentation for Clinical Record 3 on 6/14/2023 and 6/15/2023, the Director of Clinical Services confirmed there was no documentation of any information provided to the receiving hospice, including a discharge summary and no additional documentation was produced prior to the end of the site visit.

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. 3 of 4 (75%) clinical records reviewed in which the patient had a revocation, discharge, or transfer, revealed the agency did not ensure that the patient's discharge summary included a summation of the patient's hospice stay to include treatments, symptom management, and pain management, the current plan of care, and the latest physician orders. Clinical Record 2: The patient elected the hospice benefit on 1/23/2022. The "Live DC" documented on 4/12/2023 stated the patient was discharged for cause [conferred with the Director of Clinical Services on 6/15/2023 about this discharge reason, and the patient was not discharged for cause.] The Discharge Summary located under the Communication tab in the clinical record included the date of admission to hospice care, the date of discharge, the terminal diagnosis and comorbid conditions, and the reason for discharge. Under summary of care, documentation included, "Patient receiving nursing services for assistance in managing disease progression and teaching. Aide services to assist with ADLs. All other services declined." The discharge summary did not include documentation of the patient's current plan of care, medication list, or physician orders. Clinical Record 3: The patient elected the hospice benefit on 12/21/2022. In the "Live DC" documented on 2/3/2023, it was documented that the patient transferred to another hospice. The Discharge Summary located under the Communication tab in the clinical record included the date of admission to hospice care, the date of discharge, the terminal diagnosis and comorbid conditions, and the reason for discharge. Under summary of care, documentation included: "Patient receiving nursing services for assistance in managing disease progression and teaching. Aide services to assist with ADLs. All other services declined." The discharge summary did not include documentation of the patient's current plan of care, medication list, or physician orders. Clinical Record 4: The patient elected the hospice benefit on 10/13/2020. On 2/17/2023, the patient was discharged from the hospice due to moving out of the service area. "Live DC" dated 2/17/2023, stated in the comments section that the patient went to a long-term care facility Medicaid-pending. The Discharge Summary located under the Communication tab in the clinical record included the date of admission to hospice care, the date of discharge, the terminal diagnosis and comorbid conditions, and the reason for discharge. Under summary of care, the documentation included: "Patient receiving nursing services for assistance in managing disease progression and teaching. Patient was also receiving chaplain for spiritual services, MSW for community resources, and aide services to assist with ADLs." The discharge summary did not include documentation of the patient's current plan of care, medication list, or physician orders. In an interview during joint review of the discharge summary contents, CHAP standards and requirements for the discharge summary components on 6/15/2023, the Director of Clinical Services confirmed that the discharge summaries lacked the required information. No further documentation was provided prior to the end of the Site Visit.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. 5 of 9 (56%) contracts reviewed revealed the agency did not ensure that contracts required all contracted employees who have direct patient contact with hospice patients or access to patient records, to obtain a criminal background check. Contract 3: The corporate contract effective 11/1/2019 that provides the parent office with contracted PT/OT/ST services did not contain the language in the contract that anyone that comes in contact with a hospice patient or patient record information will have a criminal background check performed. Contract 7: The corporate contract effective 12/23/2020 for DME for the Alternate Delivery Site (ADS) did not contain a provision that any of the DME staff that have access to the hospice's patients or medical record information will be required to have a criminal background check. Contract 5: The corporate contract effective 3/31/2023 for the agency's Medical Director did not contain the language in the contract that a criminal background check will be required. Contract 6: The corporate contract effective 7/16/2022 for the agency's Associate Medical Director did not contain the language in the contract that a criminal background check will be required. Contract 9: The corporate contract effective 1/3/2023 that provides the ADS office with contracted PT/OT/ST services did not contain language in the contract that anyone that comes in contact with a hospice patient or patient record information will have a criminal background check performed. An interview with the Director of Clinical Services on 6/14/2023 and 6/15/2023 confirmed that the contracts reviewed (PT/ST/OT - parent and ADS, DME for ADS, and both the Medical Director and Associate Medical Director contracts) did not contain the language in the contract requiring a criminal background check for contracted staff with access to patients or patient records.

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. This standard was not met as evidenced by clinical record review and observation. 1 of 6 (17%) records reviewed revealed the agency did not ensure that the patients drug profile contained all the current medications, specifically oxygen. Record 4: The patient elected the hospice benefit on 1/16/23 with a terminal diagnosis of respiratory failure. The initial nursing comprehensive assessment, completed on 1/16/23, reported that the patient had "oxygen, continuous, at 15 Liters per NRB (non-rebreather mask)." The oxygen was listed on the Plan of Care (POC), within the respiratory problem, and was noted within the certificate of terminal illness physician narrative. During the 3/14/23 observation of the interdisciplinary team meeting the RN reported that the patient remained on continuous oxygen at 15 Liters. The drug profile, effective as of 1/16/23, did not include oxygen as a medication. During an interview, conducted on 3/14/23, with the alternate Administrator/Director of Patient Care services (DPCS) it was confirmed that oxygen had not been included on the drug profile.

It is required that a 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 CONDITION-LEVEL DEFICIENCY This CONDITION of participation was not met, as evidenced by clinical record review and interview. The agency failed to ensure that hospice aides were listed in good standing in the state registry [HSRM.9.I/L609]; and failed to ensure that hospice aides completed a competency assessment prior to providing patient care [HSRM.9.I/L615]. The cumulative effect of these deficiencies could impact the organization's ability to ensure the provision of high-quality care and services.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency programs described below. AND The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements [and] Is currently listed in good standing on the state nurse aide registry. CONTINUED PRIOR REQUIRED ACTION This standard could not be reviewed during this site visit as the organization's action plan had yet to be completed for the previous site visit conducted on 1/11/23 through 1/12/23, when the immediate jeopardy (IJ) was identified. The primary focus of this site visit conducted on 2/1/23 through 2/2/23 was to remove the IJ and assess the organization's compliance with the abatement plan. Therefore, compliance and the implementation of the action plan could not be fully evaluated. Previous Evidence: This standard was not met as evidenced by interviews and personnel records review. 1 of 3 (33%) hospice aide personnel records, the hospice did not ensure the hospice aide was listed in good standing on the state nurse aide registry. Record 6 (Hospice Aide): hire date 5/13/2021. There was no documented evidence the hospice verified the aide was listed in good standing on the state nurse aide registry prior to hiring. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence that the hospice verified the hospice aide was in good standing on the state nurse aide registry prior to or upon hire. This standard could not be reviewed during the site visits of 2/1/2023 and 2/2/2023 as the organization had not implemented its Plan of Correction. Therefore, the implementation of the Plan of Correction was unable to be evaluated. Previous Evidence: " This standard was not met as evidenced by interviews and personnel records review. 1 of 3 (33%) hospice aide personnel records, the hospice did not ensure the hospice aide was listed in good standing on the state nurse aide registry. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence the hospice verified the aide was listed in good standing on the state nurse aide registry prior to hiring. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence that the hospice verified the hospice aide was in good standing on the state nurse aide registry prior to or upon hire."

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. CONTINUED PRIOR REQUIRED ACTION This standard could not be reviewed during this site visit as the organization's action plan had yet to be completed for the previous site visit conducted on 1/11/23 through 1/12/23, when the immediate jeopardy (IJ) was identified. The primary focus of this site visit conducted on 2/1/23 through 2/2/23 was to remove the IJ and assess the organization's compliance with the abatement plan. Therefore, compliance and the implementation of the action plan could not be fully evaluated. Previous Evidence: This standard was not met as evidenced by interviews and personnel records review. 3 of 3 (100%) records of hospice aides reviewed, the hospice did not ensure that a competency assessment was completed upon hire prior to providing care. Record 5 (Hospice Aide): hire date 5/5/2021. There was no documented evidence that a competency assessment was completed. Record 6 (Hospice Aide): hire date 5/13/2021. There was no documented evidence that a competency assessment was completed. Record 8 (Hospice Aide): hire date 4/15/2021. There was no documented evidence that a competency assessment was completed. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Alternate Administrator confirmed the hospice aides identified have been making visits. This standard could not be reviewed during the site visits of 2/1/2023 and 2/2/2023 as the organization had not implemented its Plan of Correction. Therefore, the implementation of the Plan of Correction was unable to be evaluated. Previous Evidence: " This standard was not met as evidenced by interviews and personnel records review. 3 of 3 (100%) records of hospice aides reviewed, the hospice did not ensure that a competency assessment was completed upon hire prior to providing care. Record 5 (Hospice Aide): hire date 5/5/2021. There was no documented evidence that a competency assessment was completed. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence that a competency assessment was completed. Record 8 (Hospice Aide): hire date 4/15/2021. There was no documented evidence that a competency assessment was completed. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Alternate Administrator confirmed the hospice aides identified have been making visits."

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met, as evidenced by clinical records review, document review, and interview, which revealed the agency failed to ensure that Medicare approved the ADS (Alternate Delivery Site) location before providing hospice care and services to patients [HSLG.17.I/L656]; failed to ensure that the ADS shared administration and supervision with the parent site [HSLG.17.I/L657]; failed to ensure that the hospice provided an initial orientation for each employee [HSRM.15.I/L662]; and failed to ensure that the hospice assessed the skills and competence of all individuals furnishing care [HSRM.14.I/L663]. The cumulative effect and scope of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS) and ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. CONTINUED PRIOR REQUIRED ACTION This standard could not be reviewed during this site visit as the organization's action plan had yet to be completed for the previous site visit conducted on 1/11/23 through 1/12/23, when the immediate jeopardy (IJ) was identified. The primary focus of this site visit conducted on 2/1/23 through 2/2/23 was to remove the IJ and assess the organization's compliance with the abatement plan. Therefore, compliance and the implementation of the action plan could not be fully evaluated. Previous Evidence: This standard was not met, as evidenced by clinical records reviews, document reviews, and interviews. 1 of 1 (100%) alternate delivery sites reviewed, the hospice did not ensure Medicare approved the ADS location before providing hospice care and services to patients. A review of the hospice’s current state licensure revealed Hospice Alternative Delivery Site (ADS), Effective Date 10/9/2022. A review of the hospice’s active census revealed 10 patients assigned to the alternate delivery site, located 540 miles (7 hours, 7 minutes) away from the parent location. Record 3: The patient’s date of the election was 1/23/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. Record 4: The patient’s date of the election was 5/27/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence that the hospice received approval from Medicare and State prior to providing hospice care and services to patients. The Administrator was interviewed on 1/11/2023 and agreed there was no documented evidence that the alternate delivery site was approved by Medicare before providing hospice care and services to Medicare patients. The Alternate Administrator was interviewed on 1/11/2023 and agreed the alternate delivery site provides services for 10 hospice patients currently assigned to a designated ADS team. Additionally, during the interview on 1/11/2023, the Alternate Administrator agreed the location is an ADS, someone answers the phones at the location during business hours, and IDG Is held at the ADS location. It is advertised on their website and admission packet. This standard could not be reviewed during the site visits of 2/1/2023 and 2/2/2023 as the organization had not implemented its Plan of Correction. Therefore, the implementation of the Plan of Correction was unable to be evaluated. Previous Evidence: "This standard was not met, as evidenced by clinical records reviews, document reviews, and interviews. 1 of 1 (100%) alternate delivery sites reviewed, the hospice did not ensure Medicare approved the ADS location before providing hospice care and services to patients. A review of the hospice’s current state licensure revealed Hospice Alternative Delivery Site (ADS), Effective Date 10/9/2022. A review of the hospice’s active census revealed 10 patients assigned to the alternate delivery site, located 540 miles (7 hours, 7 minutes) away from the parent location. Record 3: The patient’s date of the election was 1/23/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. Record 4: The patient’s date of the election was 5/27/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the hospice received approval from Medicare and State prior to providing hospice care and services to patients. The Administrator was interviewed on 1/11/2023 and agreed there was no documented evidence the alternate delivery site was approved by Medicare before providing hospice care and services to Medicare patients. The Alternate Administrator was interviewed on 1/11/2023 and agreed the alternate delivery site provides services for 10 hospice patients currently assigned to a designated ADS team. Additionally, during the interview on 1/11/2023, the Alternate Administrator agreed the location is an ADS, someone answers the phones at the location during business hours, and IDG Is held at the ADS location. It is advertised on their website and admission packet."

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS), shares administration, supervision, and services with the hospice issued the certification number. CONTINUED PRIOR REQUIRED ACTION This standard could not be reviewed during this site visit as the organization's action plan had yet to be completed for the previous site visit conducted on 1/11/23 through 1/12/23, when the immediate jeopardy (IJ) was identified. The primary focus of this site visit conducted on 2/1/23 through 2/2/23 was to remove the IJ and assess the organization's compliance with the abatement plan. Therefore, compliance and the implementation of the action plan could not be fully evaluated. Previous Evidence: This standard was not met, as evidenced by a review of clinical records, document reviews, and interviews. 1 of 1 (100%) alternate delivery site reviewed revealed that the hospice did not ensure that all multiple locations shared supervision with the parent site. A review of the hospice’s current state licensure revealed Hospice Alternative Delivery Site (ADS), Effective Date 10/9/2022. A review of the hospice’s active census revealed 5 patients assigned to the parent location and 10 patients assigned to the alternate delivery site, located 540 miles (7 hours, 7 minutes) away from the parent location. Record 3: The patient’s date of the election was 1/23/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the alternate delivery site shares supervision with the parent site. Record 4: The patient’s date of the election was 5/27/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the alternate delivery site shares supervision with the parent site. The Hospice Medical Director was interviewed on 1/12/2023 and stated, “I only oversee the care for patients in the main location. I don’t have any interaction with the physician at that location.” The Medical Director assigned to the ADS was interviewed on 1/12/2023 and stated, “I don’t interact with the Medical Director of the other location; there are no phone calls or meetings. I can call if I need anything but never have.” The Alternate Administrator was interviewed on 1/12/2023 and stated, “I visit the ADS once a month to supervise but don’t have anything documented. I oversee both locations as Alternate Administrator and Director of Nursing. I am overwhelmed and realizing I need help.” Additionally, during an interview on 1/12/2023, the Alternate Administrator agreed there was no documented evidence the alternate delivery site shares supervision with the parent site. The Administrator was interviewed on 1/12/2023 and stated, "It was only a matter of time, we knew things weren't being done, and we are trying to get help. This standard could not be reviewed during the site visits of 2/1/2023 and 2/2/2023 as the organization had not implemented its Plan of Correction. Therefore, the implementation of the Plan of Correction was unable to be evaluated. Previous Evidence: "This standard was not met, as evidenced by a review of clinical records, document reviews, and interviews. 1 of 1 (100%) alternate delivery site reviewed revealed that the hospice did not ensure that all multiple locations shared supervision with the parent site. A review of the hospice’s current state licensure revealed Hospice Alternative Delivery Site (ADS), Effective Date 10/9/2022. A review of the hospice’s active census revealed 5 patients assigned to the parent location and 10 patients assigned to the alternate delivery site, located 540 miles (7 hours, 7 minutes) away from the parent location. Record 3: The patient’s date of the election was 1/23/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the alternate delivery site shares supervision with the parent site. Record 4: The patient’s date of the election was 5/27/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the alternate delivery site shares supervision with the parent site. The Hospice Medical Director was interviewed on 1/12/2023 and stated, “I only oversee the care for patients in the main location. I don’t have any interaction with the physician at that location.” The Medical Director assigned to the ADS was interviewed on 1/12/2023 and stated, “I don’t interact with the Medical Director of the other location; there are no phone calls or meetings. I can call if I need anything but never have.” The Alternate Administrator was interviewed on 1/12/2023 and stated, “I visit the ADS once a month to supervise but don’t have anything documented. I oversee both locations as Alternate Administrator and Director of Nursing. I am overwhelmed and realizing I need help.” Additionally, during an interview on 1/12/2023, the Alternate Administrator agreed there was no documented evidence the alternate delivery site shares supervision with the parent site. The Administrator was interviewed on 1/12/2023 and stated, "It was only a matter of time, we knew things weren't being done, and we are trying to get help."

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. CONTINUED PRIOR REQUIRED ACTION This standard could not be reviewed during this site visit as the organization's action plan had yet to be completed for the previous site visit conducted on 1/11/23 through 1/12/23, when the immediate jeopardy (IJ) was identified. The primary focus of this site visit conducted on 2/1/23 through 2/2/23 was to remove the IJ and assess the organization's compliance with the abatement plan. Therefore, compliance and the implementation of the action plan could not be fully evaluated. Previous Evidence: This standard was not met, as evidenced by interviews and personnel records review. 3 of 5 (60%) records of employees hired on or after July 17, 2020, reviewed, revealed the hospice did not ensure an initial orientation was provided. Record 4 (Registered Nurse): hire date 2/17/2022. There was no documented evidence of the initial orientation. Record 5 (Hospice Aide): hire date 5/5/2021. There was no documented evidence of the initial orientation. Record 6 (Hospice Aide): hire date 5/13/2021. There was no documented evidence of the initial orientation. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the orientation checklist was completed. This standard could not be reviewed during the site visits of 2/1/2023 and 2/2/2023 as the organization had not implemented its Plan of Correction. Therefore, the implementation of the Plan of Correction was unable to be evaluated. Previous Evidence: "This standard was not met, as evidenced by interviews and personnel records review. 3 of 5 (60%) records of employees hired on or after July 17, 2020, reviewed, revealed the hospice did not ensure an initial orientation was provided. Record 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence of the initial orientation. Record 5 (Hospice Aide): hire date 5/5/2021. There was no documented evidence of the initial orientation. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence of the initial orientation. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the orientation checklist was completed."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. CONTINUED PRIOR REQUIRED ACTION This standard could not be reviewed during this site visit as the organization's action plan had yet to be completed for the previous site visit conducted on 1/11/23 through 1/12/23, when the immediate jeopardy (IJ) was identified. The primary focus of this site visit conducted on 2/1/23 through 2/2/23 was to remove the IJ and assess the organization's compliance with the abatement plan. Therefore, compliance and the implementation of the action plan could not be fully evaluated. Previous Evidence: It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met, as evidenced by interviews and personnel records review. 1 of 2 (50%) records of registered nurses hired on or after July 17, 2020 reviewed, revealed the hospice did not ensure a competency assessment was completed upon hire. Record 4 (Registered Nurse): hire date 2/17/2022. There was no documented evidence a competency assessment was completed upon hire. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence a competency assessment was completed. The Alternate Administrator stated, “this should have been done before the nurse was on her own; it’s missing. This standard could not be reviewed during the site visits of 2/1/2023 and 2/2/2023 as the organization had not implemented its Plan of Correction. Therefore, the implementation of the Plan of Correction was unable to be evaluated. Previous Evidence: "It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met, as evidenced by interviews and personnel records review. 1 of 2 (50%) records of registered nurses and hospice physicians hired on or after July 17, 2020 reviewed, revealed the hospice did not ensure a competency assessment was completed upon hire. Record 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence a competency assessment was completed upon hire. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence a competency assessment was completed. The Alternate Administrator stated, “this should have been done before the nurse was on her own; it’s missing.”

It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice: Are legally authorized (licensed, certified, or registered) in accordance with local, state, and federal law and regulation; Act only within the scope of their state license or state certification or registration; Keep their qualifications current at all times. CONTINUED PRIOR REQUIRED ACTION This standard could not be reviewed during this site visit as the organization's action plan had yet to be completed for the previous site visit conducted on 1/11/23 through 1/12/23, when the immediate jeopardy (IJ) was identified. The primary focus of this site visit conducted on 2/1/23 through 2/2/23 was to remove the IJ and assess the organization's compliance with the abatement plan. Therefore, compliance and the implementation of the action plan could not be fully evaluated. Previous Evidence: This standard was not met, as evidenced by document reviews, interviews, and personnel records. 1 of 2 (50%) records reviewed of physicians, the hospice did not ensure the medical license was verified upon expiration. Agency policy, “Personnel Records, HR.11,” stated in part, “License or certification verification. When current licensure, certification, or registration are required by law or regulation to practice a profession, the organization verified these credentials at the time of hire and upon expiration of credentials.” Record 7 (Medical Director): hire date 7/18/2022. There was no documented evidence the physician’s medical license was verified upon the expiration date of 11/30/2022. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the physician's medical license was verified upon expiration. This standard could not be reviewed during the site visits of 2/1/2023 and 2/2/2023 as the organization had not implemented its Plan of Correction. Therefore, the implementation of the Plan of Correction was unable to be evaluated. Previous Evidence: "This standard was not met, as evidenced by document reviews, interviews, and personnel records. 1 of 2 (50%) records reviewed of physicians, the hospice did not ensure the medical license was verified upon expiration. Agency policy, “Personnel Records, HR.11,” stated in part, “License or certification verification. When current licensure, certification, or registration are required by law or regulation to practice a profession, the organization verified these credentials at the time of hire and upon expiration of credentials.” Record 7 (Medical Director-EP): hire date 7/18/2022. There was no documented evidence the physician’s medical license was verified upon the expiration date of 11/30/2022. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the physician's medical license was verified upon expiration."

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of the COVID-19 vaccine or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment or other services for the hospice and/or its patients/families. Or there is evidence of an individual having a pending request for or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. CONTINUED PRIOR REQUIRED ACTION This standard could not be reviewed during this site visit as the organization's action plan had yet to be completed for the previous site visit conducted on 1/11/23 through 1/12/23, when the immediate jeopardy (IJ) was identified. The primary focus of this site visit conducted on 2/1/23 through 2/2/23 was to remove the IJ and assess the organization's compliance with the abatement plan. Therefore, compliance and the implementation of the action plan could not be fully evaluated. Previous Evidence: This standard was not met, as evidenced by an interview and personnel records review. 5 of 8 (62%) records reviewed revealed the hospice did not ensure the employees were fully vaccinated for COVID-19 or had an approved exemption. Record # 1 (Administrator): hire date 10/1/2018. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption. Record #3 (Medical Director): hire date 1/31/2019. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption. Record # 4 (Registered Nurse): hire date 2/17/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record # 6 (Hospice Aide): hire date 5/13/2021. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record #7 (Medical Director): hire date 7/18/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption in the records identified. This standard could not be reviewed during the site visits of 2/1/2023 and 2/2/2023 as the organization had not implemented its Plan of Correction. Therefore, the implementation of the Plan of Correction was unable to be evaluated. Previous Evidence: "This standard was not met, as evidenced by an interview and personnel records review. 5 of 8 (62%) records reviewed revealed the hospice did not ensure the employees were fully vaccinated for COVID-19 or had an approved exemption. Record # 1 (Administrator): hire date 10/1/2018. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption. Record #3 (Medical Director): hire date 1/31/2019. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption. Record # 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record # 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record #7 (Medical Director-EP): hire date 7/18/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption in the records identified."

It is required that during the initial assessment visit and in advance of providing care: The hospice provides the patient—or his or her representative—with verbal and written notice of the patient’s rights and responsibilities. This information is provided in a language and manner that the patient understands. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met, as evidenced by a review of clinical records and interviews. 2 of 6 (33%) records reviewed; the hospice did not ensure the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. Record 5: The patient’s date of the election was 12/21/2022. There was no documented evidence the hospice obtained the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities. Record 6: The patient’s date of the election was 11/8/2022. There was no documented evidence the hospice obtained the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the hospice obtained the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence the hospice obtained the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities. Record 6: The patient’s date of election was 11/8/2022. There was no documented evidence the hospice obtained the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the hospice obtained the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities.

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 DEFICIENCY This Condition was not met, as evidenced by clinical records review, document review, and interview, which revealed issues with the completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to demonstrate completion of spiritual and bereavement assessment, as part of the initial comprehensive assessment, within five (5) calendar days after the election of hospice care (HCPC.9.I/L523); failure of the hospice Interdisciplinary Group to ensure the initial comprehensive assessment included a review of all of the patient's medications for adverse effects, significant side effects, and contraindications (HCPC.15.I/L530); and failure of the hospice Interdisciplinary Group to demonstrate completion of an initial bereavement assessment (HCPC.13.I/L531). The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to identify and meet the care needs of the patients and ensure continuity of care and service coordination.

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). The physician, patient, or representative may request that the initial hospice assessment be completed in less than 48 hours. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 6 (17%) records reviewed, the hospice did not ensure the registered nurse completed an initial assessment within 48 hours of the patient’s election of hospice care. Record 5: The patient’s date of election was 12/21/2022. The registered nurse initial assessment on 12/21/2022 was blank and did not include any assessment information. There was no documented evidence an initial comprehensive assessment was completed within 48 hours of the election of hospice care. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the initial comprehensive assessment was completed. Record 5: The patient’s date of election was 12/21/2022. The registered nurse initial assessment on 12/21/2022 was blank and did not include any assessment information. There was no documented evidence an initial comprehensive assessment was completed within 48 hours of the election of hospice care. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the initial comprehensive assessment was completed.

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 of the hospice care election statement. This standard was not met, as evidenced by clinical records review and interview. 1 of 6 (17%) records reviewed, the hospice did not ensure the initial spiritual assessment was completed by five (5) calendar days after the election of hospice care. Record 5: The patient’s date of the election was 12/21/2022. The spiritual assessment on 12/22/2022 did not include any assessment information or assessment of the patient’s and family’s spiritual needs. There was no documented evidence an initial spiritual evaluation was completed no later than five days after the election of hospice care. The Alternate Administrator was interviewed on 1/12/2023 and agreed the initial spiritual assessment was not completed. Record 5: The patient’s date of election was 12/21/2022. The spiritual assessment on 12/22/2022 did not include any assessment information or assessment of the patient’s and family’s spiritual needs. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. The Alternate Administrator was interviewed on 1/12/2023 and agreed, the initial spiritual assessment was not completed.

The documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; 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. 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. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 6 (17%) records reviewed, the hospice did not ensure that the initial comprehensive assessment included a review of all the patient’s medications for adverse effects, significant side effects, and contraindications. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence that medication orders were received. There was no documented evidence of a medication profile or review. There was no documented evidence of an IDG (Interdisciplinary Group) medication review. The facility manager was interviewed on 1/12/2023 and stated, the patient medications include: Seroquel (started 12/21/2022-discontinued 12/31/2022), Trazadone (started 12/21/2022), Haldol “taking several times daily,” Ambien 10mg (started 1/5/2023), Lisinopril, Benzonatate and Zolpidem 5mg. The Alternate Administrator was interviewed on 1/12/2023 and stated, “I did this admission and didn’t get orders or document it.” The Alternate Administrator agreed, there was no documented evidence of written or verbal physician’s orders for the medications, there were no medications on the medication profile, there were no IDG meetings documented. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence that medication orders were received. There was no documented evidence of a medication profile or review. There was no documented evidence of an IDG (Interdisciplinary Group) medication review. The facility manager was interviewed on 1/12/2023 and stated, the patient medications include: Seroquel (started 12/21/2022-discontinued 12/31/2022), Trazadone (started 12/21/2022), Haldol “taking several times daily,” Ambien 10mg (started 1/5/2023), Lisinopril, Benzonatate and Zolpidem 5mg. The Alternate Administrator was interviewed on 1/12/2023 and stated, “I did this admission and didn’t get orders or document it.” The Alternate Administrator agreed, there was no documented evidence of written or verbal physician’s orders for the medications, there were no medications on the medication profile, there were no IDG meetings documented.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 6 (50%) records reviewed, the hospice did not ensure an initial bereavement assessment was completed. Record 1: The patient’s date of election was 10/16/2020. There was no documented evidence an initial bereavement assessment was completed. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence an initial bereavement assessment was completed. Record 6: The patient’s date of election was 11/8/2022. There was no documented evidence an initial bereavement assessment was completed. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the initial bereavement assessments were completed. Record 1: The patient’s date of election was 10/16/2020. There was no documented evidence an initial bereavement assessment was completed. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence an initial bereavement assessment was completed. Record 6: The patient’s date of election was 11/8/2022. There was no documented evidence an initial bereavement assessment was completed. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the initial bereavement assessments were completed.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement.IDG members provide the care and services offered by the organization. THIS IS A CMS CONDITION-LEVEL DEFICIENCY. This Condition was not met, as evidenced by clinical record review, document review, and interview which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure of the hospice Interdisciplinary Group to develop a documented patient plan of care (HCPC.18.I/L537); failure of the hospice Interdisciplinary Group to ensure hospice care and services were provided and coordinated to meet the patient's care needs (HCPC.1.I/L539); failure of the hospice to designate a registered nurse member of the interdisciplinary group to provide coordination of care and ensure continuous assessment of the patient's and family's needs and implementation of the interdisciplinary plan of care (HCPC.19.I/L540) and failure of the Interdisciplinary Group to document review and revision of patients’ care plans as frequently as the patient's condition requires, but no less frequently than every 15 calendar days (HCPC.22.I/L552). As a result of substantial non-compliance with the conditions of participation, including the failure of the hospice to ensure the management and oversight of its administrative and clinical operations, all of which could pose actual or potential serious injury, harm, impairment, or death to patients served by the hospice, a determination of IMMEDIATE JEOPARDY was made.

It is required that the plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment relative to the terminal illness and associated conditions. This standard was not met, as evidenced by clinical records review and interview. 1 of 6 (17%) records reviewed, the hospice Interdisciplinary Group (IDG) failed to ensure a hospice plan of care was developed with physician orders for medications and services necessary to meet the specific needs of the patient and family, as identified in the comprehensive assessments. Record 5: The patient’s date of the election was 12/21/2022. There was no documented evidence of a medication profile, verbal physician's orders, or signed physician’s orders. There was no documented evidence the IDG initiated a plan of care for the patient. There was no documented evidence of IDG Meetings. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence of a medication profile, verbal physician's orders, or signed physician’s orders. The Alternate Administrator agreed there was no documented evidence of IDG Meetings or that the IDG initiated a plan of care for the patient. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence of a medication profile, verbal physician's orders, or signed physician’s orders. There was no documented evidence a plan of care was initiated by the IDG for the patient. There was no documented evidence of IDG Meetings. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence of a medication profile, verbal physician's orders, and signed physician’s orders. The Alternate Administrator agreed, there was no documented evidence of IDG Meetings or that a plan of care was initiated by the IDG for the patient.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met, as evidenced by clinical records review and interview. 5 of 6 (83%) records reviewed, the hospice did not ensure the Interdisciplinary Group provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record #1: The patient’s date of the election was 10/16/2020. A review of the plans of care between May and November 2022 revealed the chaplain visit frequency was 1 x month. There were no documented chaplain visits or reasons for the missed visits in May, June, July, August, October, or November. The skilled nurse visit frequency on 10/28/2022 ordered skilled nurse 1 x weekly. A nurse assessment was documented on 11/4/2022. There were no documented nurse visits between 11/6/2022 and 1/10/2023. There was no documented evidence of an initial bereavement assessment. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record # 3: The patient’s date of the election was 1/23/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record # 4: The patient’s date of the election was 5/27/2022. A review of the plan of care on 10/25/2022 revealed the chaplain frequency was 2 x month. There was a chaplain visit documented on 11/17/2022. There was no documented evidence of a second chaplain visit in November or reason for the missed visit. The visit frequency starting 10/25/2022 ordered skilled nurse 1 x week. There were no documented nurse visits between 10/30/2022 and 1/10/2023. Record 4: The patient’s date of the election was 5/27/2022. A physician’s order on 11/14/2022 ordered a hospice aide 3 x week. During the week of 12/25/2022-12/31/2022, there was a hospice aide visit on 12/26/2022. There was no documented evidence of a second or third hospice aide visit or documented reasons for the missed visits. During the week of 1/1/2023-1/7/2023, there were no hospice aide visits or documented reasons for the missed visits. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record # 5: The patient’s date of the election was 12/21/2022. There was no documented evidence of a medication profile, verbal physician's orders, or signed physician’s orders. There was no documented evidence a plan of care was initiated. There was no documented evidence of a comprehensive nursing assessment. There was no documented evidence of an initial spiritual evaluation or initial bereavement assessment. The patient’s date of the election was 12/21/2022. A review of the patient’s schedule revealed hospice aide visits scheduled 2 x week for 12/21/2022-12/24/2022, 4 x week for 12/25/2022-12/31/2022, 4 x week for 1/1/2023-1/7/2023. There was no documented evidence of a physician’s order or hospice aide care plan for the hospice aide visits. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 12/21/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record # 6: The patient’s date of the election was 11/8/2022. There was no documented evidence of an initial bereavement assessment. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record 1: The patient’s date of election was 10/16/2020. Review of the plans of care between May and November 2022 revealed the chaplain visit frequency was 1 x month. There were no documented chaplain visits or reasons for the missed visits in May, June, July, August, October, or November. The skilled nurse visit frequency on 10/28/2022 ordered skilled nurse 1 x weekly. A nurse assessment was documented on 11/4/2022. There were no documented nurse visits between 11/6/2022 and 1/10/2023. There was no documented evidence of an initial bereavement assessment. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record 3: The patient’s date of election was 1/23/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record 4: The patient’s date of election was 5/27/2022. Review of the plan of care on 10/25/2022 revealed the chaplain frequency was 2 x month. There was a chaplain visit documented on 11/17/2022. There was no documented evidence of a second chaplain visit in November or reason for the missed visit. The visit frequency starting 10/25/2022 ordered skilled nurse 1 x week. There were no documented nurse visits between 10/30/2022 and 1/10/2023. Record 4: The patient’s date of election was 5/27/2022. A physician’s order on 11/14/2022 ordered a hospice aide 3 x week. During the week 12/25/2022-12/31/2022, there was a hospice aide visit on 12/26/2022. There was no documented evidence of a second or third hospice aide visit or documented reasons for the missed visits. During the week 1/1/2023-1/7/2023, there were no hospice aide visits or documented reasons for the missed visits. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence of a medication profile, verbal physician's orders, or signed physician’s orders. There was no documented evidence a plan of care was initiated. There was no documented evidence of a nursing comprehensive assessments. There was no documented evidence of an initial spiritual assessment or initial bereavement assessment. The patient’s date of election was 12/21/2022. Review of the patient’s schedule revealed hospice aide visits scheduled 2 x week for 12/21/2022-12/24/2022, 4 x week for 12/25/2022-12/31/2022, 4 x week for 1/1/2023-1/7/2023. There was no documented evidence of a physician’s order or hospice aide care plan for the hospice aide visits. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 12/21/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Record 6: The patient’s date of election was 11/8/2022. There was no documented evidence of an initial bereavement assessment. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. There was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family.

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. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician, patient and primary caregiver. This standard was not met, as evidenced by clinical records review and interviews. 3 of 6 (50%) records reviewed, the hospice did not ensure a Registered Nurse was designated to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care. There was no documented evidence that an RN was designated to provide care coordination to ensure the continuous assessment of each patient's and family's needs and ensure the plan of care was followed. Record 1: The patient’s date of the election was 10/16/2020. A review of the plans of care between May and November 2022 revealed the chaplain visit frequency was 1 x month. There were no documented chaplain visits or reasons for the missed visits in May, June, July, August, October, or November. The skilled nurse visit frequency on 10/28/2022 ordered skilled nurse 1 x weekly. A nurse assessment was documented on 11/4/2022. There were no documented nurse visits between 11/6/2022 and 1/10/2023. There were no documented reasons for the missed visits. Record 4: The patient’s date of the election was 5/27/2022. A review of the plan of care on 10/25/2022 revealed the chaplain frequency was 2 x month. There was a chaplain visit documented on 11/17/2022. There was no documented evidence of a second chaplain visit in November or reason for the missed visit. The visit frequency starting 10/25/2022 ordered skilled nurse 1 x week. There were no documented nurse visits between 10/30/2022 and 1/10/2023. There were no documented reasons for the missed visits. Record 5: The patient’s date of the election was 12/21/2022. There was no documented evidence an initial comprehensive nursing assessment was completed within 48 hours of the election of hospice care. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence a registered nurse provided coordination of care and ensured continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care. Record 1: The patient’s date of election was 10/16/2020. Review of the plans of care between May and November 2022 revealed the chaplain visit frequency was 1 x month. There were no documented chaplain visits or reasons for the missed visits in May, June, July, August, October, or November. The skilled nurse visit frequency on 10/28/2022 ordered skilled nurse 1 x weekly. A nurse assessment was documented on 11/4/2022. There were no documented nurse visits between 11/6/2022 and 1/10/2023. There were no documented reasons for the missed visits. Record 4: The patient’s date of election was 5/27/2022. Review of the plan of care on 10/25/2022 revealed the chaplain frequency was 2 x month. There was a chaplain visit documented on 11/17/2022. There was no documented evidence of a second chaplain visit in November or reason for the missed visit. The visit frequency starting 10/25/2022 ordered skilled nurse 1 x week. There were no documented nurse visits between 10/30/2022 and 1/10/2023. There were no documented reasons for the missed visits. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence an initial comprehensive nursing assessment was completed within 48 hours of the election of hospice care. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence a registered nurse provided coordination of care and ensured continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment; record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met, as evidenced by clinical records review and interviews. 5 of 6 (83%) records reviewed revealed the failure of the hospice Interdisciplinary Group to ensure Interdisciplinary Group to document review and revision of patients’ care plans as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. Record #1: The patient’s date of the election was 10/16/2020. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. Record #3: The patient’s date of the election was 1/23/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. Record #4: The patient’s date of the election was 5/27/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. Record #5: The patient’s date of the election was 12/21/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 12/21/2022-1/10/2023. Record# 6: The patient’s date of the election was 11/8/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. The Alternate Administrator was interviewed on 1/12/2023 and stated, “there may be a sign in sheets somewhere.” Additionally, during the interview 1/12/2023, the Alternate Administrator agreed there was no documented evidence the IDG reviewed the plan of care during the IDG meeting in the records identified. Record 1: The patient’s date of election was 10/16/2020. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. Record 3: The patient’s date of election was 1/23/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. Record 4: The patient’s date of election was 5/27/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 12/21/2022-1/10/2023. Record 6: The patient’s date of election was 11/8/2022. There was no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care between 11/23/2022-1/10/2023. The Alternate Administrator was interviewed on 1/12/2023 and stated, “there may be sign in sheets somewhere.” Additionally, during interview 1/12/2023, the Alternate Administrator agreed, there was no documented evidence the IDG reviewed the plan of care during the IDG meeting in the records identified.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s Ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met, as evidenced by interviews and documents review, which revealed the governing body did not ensure that ongoing quality performance improvement and patient safety were defined, implemented, and maintained. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the governing body ensured that ongoing quality performance improvement and patient safety were defined, implemented, and maintained. Additionally, during an interview on 1/12/2023, the Alternate Administrator stated, “we do not have anything documented for QAPI or governing body; we have no meetings or notes or anything,” The Administrator was interviewed on 1/12/2023 and agreed there needed to be more information to provide for QAPI or governing body. Additionally, during an interview on 1/12/2023, the Administrator stated, “we are looking to hire help for QAPI because we do not have a QAPI program right now.” which revealed the governing body did not ensure that ongoing quality performance improvement and patient safety were defined, implemented and maintained. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the governing body ensured that ongoing quality performance improvement and patient safety were defined, implemented and maintained. Additionally, during interview on 1/12/2023, the Alternate Administrator stated, “we do not have anything documented for QAPI or governing body, we have no meetings or notes or anything,” The Administrator was interviewed on 1/12/2023 and agreed, there was no information to provide for QAPI or governing body. Additionally, during interview on 1/12/2023, the Administrator stated, “we are looking to hire help for QAPI because we do not have a QAPI program right now.”

It is required that a 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 CONDITION LEVEL DEFICIENCY This CONDITION of participation was not met as evidenced by clinical record review and interview. The agency failed: to ensure written patient care plan was developed by a RN who was responsible for the supervision of the hospice aide [HCDT.15.I/625]; and failed to ensure that the aide followed the care plan [HCDT.16.I/L626]; failed to ensure the hospice aides were listed in good standing in the state registry [HSRM.9.I/L609]; and failed toensure the hospice aides completed a competency assessment piror to providing patient care [HSRM.9.I/L615].The cumulative effect of these deficiencies could impact the organization's ability to ensure high-quality care and services.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency programs described below. AND The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. (L609) AND The hospice maintains documentation that each hospice aide has met the requirements. (L614) Is currently listed in good standing on the state nurse aide registry. This standard was not met as evidenced by interviews and personnel records review. 1 of 3 (33%) hospice aide personnel records, the hospice did not ensure the hospice aide was listed in good standing on the state nurse aide registry. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence the hospice verified the aide was listed in good standing on the state nurse aide registry prior to hire. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence that the hospice verified the hospice aide was in good standing on the state nurse aide registry prior to or upon hire. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence the hospice verified the aide was listed in good standing on the state nurse aide registry prior to hire. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence that the hospice verified the hospice aide was in good standing on the state nurse aide registry prior to or upon hire.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the . This standard was not met as evidenced by interviews and personnel records review. 3 of 3 (100%) records of hospice aides reviewed, the hospice did not ensure that a competency assessment was completed upon hire prior to providing care. Record 5 (Hospice Aide): hire date 5/5/2021. There was no documented evidence that a competency assessment was completed. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence that a competency assessment was completed. Record 8 (Hospice Aide): hire date 4/15/2021. There was no documented evidence that a competency assessment was completed. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Alternate Administrator confirmed the hospice aides identified have been making visits. Record 5 (Hospice Aide): hire date 5/5/2021. There was no documented evidence that a competency assessment was completed. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence that a competency assessment was completed. Record 8 (Hospice Aide): hire date 4/15/2021. There was no documented evidence that a competency assessment was completed. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Alternate Administrator confirmed the hospice aides identified have been making visits.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met, as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records of those who received hospice aide services revealed the agency did not ensure that the registered nurse provided written care instructions for the hospice aide assignment. Record 5: The patient’s date of the election was 12/21/2022. A review of the patient’s schedule revealed hospice aide visits scheduled 2 x weeks for 12/21/2022-12/24/2022, 4 x week for 12/25/2022-12/31/2022, 4 x week for 1/1/2023-1/7/2023. There was no documented evidence of a hospice aide plan of care. The Hospice Aide (Staff 8) was interviewed on 1/12/2023 and stated, “I’ve done all the scheduled visits but can’t document because there’s no plan of care.” The Alternate Administrator was interviewed on 1/12/2023 and stated, “I did the admission and forgot to put a plan of care in for the aide.” Record 5: The patient’s date of election was 12/21/2022. Review of the patient’s schedule revealed hospice aide visits scheduled 2 x week for 12/21/2022-12/24/2022, 4 x week for 12/25/2022-12/31/2022, 4 x week for 1/1/2023-1/7/2023. There was no documented evidence of a hospice aide plan of care. The Hospice Aide (Staff 8) was interviewed on 1/12/2023 and stated, “I’ve done all the scheduled visits but can’t document because there’s no plan of care.” The Alternate Administrator was interviewed on 1/12/2023 and stated, “I did the admission and forgot to put a plan of care in for the aide.”

It is required that a 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 standard was not met, as evidenced by a review of clinical records and interviews. 3 of 5 (60%) applicable records of patients who received hospice aide services revealed the agency did not ensure that the hospice aide provided services as ordered. Record 4: The patient’s date of the election was 5/27/2022. A physician’s order on 11/14/2022 ordered a hospice aide 3 x week. During the week of 12/25/2022-12/31/2022, there was a hospice aide visit on 12/26/2022. There was no documented evidence of a second or third hospice aide visit or documented reasons for the missed visits. During the week of 1/1/2023-1/7/2023, there were no hospice aide visits or documented reasons for the missed visits. Record 5: The patient’s date of the election was 12/21/2022. A review of the patient’s schedule revealed hospice aide visits scheduled 2 x weeks for 12/21/2022-12/24/2022, 4 x week for 12/25/2022-12/31/2022, 4 x week for 1/1/2023-1/7/2023. There was no documented evidence of a physician’s order for the hospice aide visits. The Hospice Aide (Staff 8) was interviewed on 1/12/2023 and stated, “I’ve done all the scheduled visits (Record 5) but can’t document because there’s no plan of care. I’ve been doing shower, dressing, ambulate to the bathroom, the facility told me to shower.” Record 6: The patient’s date of the election was 11/8/2022. The hospice aide care plan on 11/8/2022 did not order bathing. The Hospice Aide (Staff 8) was interviewed on 1/12/2023 and stated, “I have been doing a bed bath or shower (Record 6), depending on what the facility requests.” The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the hospice aides provided care as ordered. Record 4: The patient’s date of election was 5/27/2022. A physician’s order on 11/14/2022 ordered a hospice aide 3 x week. During the week 12/25/2022-12/31/2022, there was a hospice aide visit on 12/26/2022. There was no documented evidence of a second or third hospice aide visit or documented reasons for the missed visits. During the week 1/1/2023-1/7/2023, there were no hospice aide visits or documented reasons for the missed visits. Record 5: The patient’s date of election was 12/21/2022. Review of the patient’s schedule revealed hospice aide visits scheduled 2 x week for 12/21/2022-12/24/2022, 4 x week for 12/25/2022-12/31/2022, 4 x week for 1/1/2023-1/7/2023. There was no documented evidence of a physician’s order for the hospice aide visits. The Hospice Aide (Staff 8) was interviewed on 1/12/2023 and stated, “I’ve done all the scheduled visits (Record 5) but can’t document because there’s no plan of care. I’ve been doing shower, dressing, ambulate to bathroom, the facility told me to shower.” Record 6: The patient’s date of election was 11/8/2022. The hospice aide care plan on 11/8/2022 did not order bathing. The Hospice Aide (Staff 8) was interviewed on 1/12/2023 and stated, “I have been doing a bed bath or shower (Record 6), depending on what the facility requests.” The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the hospice aides provided care as ordered.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met, as evidenced by clinical records review, document review, and interview. This Condition of Participation was not met, as evidenced by clinical records review, documents review, and interviews which revealed a failure by the Governing Body to assume responsibility for the organization’s overall management and operations and ongoing performance improvement and patient safety program that is defined, implemented, maintained and evaluated annually HSLG.2.I/L651]; failure to ensure that Medicare approved the ADS location before providing hospice care and services to patients [HSLG.17.I/L656]; failure to ensure that the hospice did not ensure that all multiple locations shared supervision with the parent site [HSLG.17.I/L657]; failure to ensure that the hospice did not ensure an initial orientation was provided [HSRM.15.I/L662]; failed to ensure that the hospice did not ensure a competency assessment was completed upon hire [HSRM.14.I/L663]; and failed to ensure that ongoing quality performance improvement and patient safety were defined, implements ad maintained [HSLG.2.I/L574]. The cumulative effect and scope of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation and provision of care and services. This standard was not met, as evidenced by document reviews and interviews, which revealed the governing body did not assume full responsibility for the organization’s overall management, operation, and provision of care and services. Record # 5 was reviewed and identified an election of hospice on 12/21/2022. There was no documented evidence of overall management of the operations as evidenced by no documentation of an initial assessment or identification of patient needs, the lack of development of the plan of care, missing physician orders that medication orders, a medication profile or review, the lack of development of the aide plan of care. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence of a medication profile, verbal physician's orders, or signed physician’s orders. The Alternate Administrator agreed there was no documented evidence of IDG Meetings or that the IDG initiated a plan of care for the patient. The Hospice Aide (Staff 8) was interviewed on 1/12/2023 and stated, “I’ve done all the scheduled visits but can’t document because there’s no plan of care.” The Alternate Administrator was interviewed on 1/12/2023 and stated, “I did the admission and forgot to put a plan of care in for the aide.” which revealed the governing body did not assume full responsibility for the organization’s overall management, operation, and provision of care and services. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the governing body ensured that ongoing quality performance improvement and patient safety were defined, implemented and maintained. Additionally, during interview on 1/12/2023, the Alternate Administrator stated, “we do not have anything documented for QAPI or governing body, we have no meetings or notes or anything,” The Administrator was interviewed on 1/12/2023 and agreed, there was no information to provide for QAPI or governing body. Additionally, during interview on 1/12/2023, the Administrator stated, “we are looking to hire help for QAPI because we do not have a QAPI program right now.”

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS) and ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. This standard was not met, as evidenced by clinical records reviews, document reviews, and interviews. 1 of 1 (100%) alternate delivery sites reviewed, the hospice did not ensure Medicare approved the ADS location before providing hospice care and services to patients. A review of the hospice’s current state licensure revealed Hospice Alternative Delivery Site (ADS), Effective Date 10/9/2022. A review of the hospice’s active census revealed 10 patients assigned to the alternate delivery site, located 540 miles (7 hours, 7 minutes) away from the parent location. Record 3: The patient’s date of the election was 1/23/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. Record 4: The patient’s date of the election was 5/27/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the hospice received approval from Medicare and State prior to providing hospice care and services to patients. The Administrator was interviewed on 1/11/2023 and agreed there was no documented evidence the alternate delivery site was approved by Medicare before providing hospice care and services to Medicare patients. The Alternate Administrator was interviewed on 1/11/2023 and agreed the alternate delivery site provides services for 10 hospice patients currently assigned to a designated ADS team. Additionally, during the interview on 1/11/2023, the Alternate Administrator agreed the location is an ADS, someone answers the phones at the location during business hours, and IDG Is held at the ADS location. It is advertised on their website and admission packet. Review of the hospice’s current state licensure revealed, Hospice Alternative Delivery Site (ADS), Effective Date 10/9/2022. Review of the hospice’s active census revealed 10 patients assigned to the alternate delivery site, located 540 miles (7 hours, 7 minutes) away from the parent location. Record 3: The patient’s date of election was 1/23/2022. Review of the clinical record revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. Record 4: The patient’s date of election was 5/27/2022. Review of the clinical record revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the hospice received approval by Medicare and State prior to providing hospice care and services to patients. The Administrator was interviewed on 1/11/2023 and agreed, there was no documented evidence the alternate delivery site was approved by Medicare and State before providing hospice care and services to Medicare patients. The Alternate Administrator was interviewed on 1/11/2023 and agreed, the alternate delivery site provides services for 10 hospice patients currently assigned to a designated ADS team. Additionally, during interview on 1/11/2023, the Alternate Administrator agreed, the location is an ADS, someone answers the phones at the location during business hours, IDG Is held at the ADS location, it is advertised on their website and admission packet.

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS), shares administration, supervision, and services with the hospice issued the certification number. This standard was not met, as evidenced by a review of clinical records, document reviews, and interviews. 1 of 1 (100%) alternate delivery site reviewed revealed that the hospice did not ensure that all multiple locations shared supervision with the parent site. A review of the hospice’s current state licensure revealed Hospice Alternative Delivery Site (ADS), Effective Date 10/9/2022. A review of the hospice’s active census revealed 5 patients assigned to the parent location and 10 patients assigned to the alternate delivery site, located 540 miles (7 hours, 7 minutes) away from the parent location. Record 3: The patient’s date of the election was 1/23/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the alternate delivery site shares supervision with the parent site. Record 4: The patient’s date of the election was 5/27/2022. A clinical record review revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the alternate delivery site shares supervision with the parent site. The Hospice Medical Director was interviewed on 1/12/2023 and stated, “I only oversee the care for patients in the main location. I don’t have any interaction with the physician at that location.” The Medical Director assigned to the ADS was interviewed on 1/12/2023 and stated, “I don’t interact with the Medical Director of the other location; there are no phone calls or meetings. I can call if I need anything but never have.” The Alternate Administrator was interviewed on 1/12/2023 and stated, “I visit the ADS once a month to supervise but don’t have anything documented. I oversee both locations as Alternate Administrator and Director of Nursing. I am overwhelmed and realizing I need help.” Additionally, during an interview on 1/12/2023, the Alternate Administrator agreed there was no documented evidence the alternate delivery site shares supervision with the parent site. The Administrator was interviewed on 1/12/2023 and stated, "It was only a matter of time, we knew things weren't being done, and we are trying to get help." Review of the hospice’s current state licensure revealed, Hospice Alternative Delivery Site (ADS), Effective Date 10/9/2022. Review of the hospice’s active census revealed 5 patients assigned to the parent location and 10 patients assigned to the alternate delivery site, located 540 miles (7 hours, 7 minutes) away from the parent location. Record 3: The patient’s date of election was 1/23/2022. Review of the clinical record revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the alternate delivery site shares supervision with the parent site. Record 4: The patient’s date of election was 5/27/2022. Review of the clinical record revealed the patient was assigned to the alternate delivery site (ADS) and receiving hospice care and services. There was no documented evidence the alternate delivery site shares supervision with the parent site. The Hospice Medical Director was interviewed on 1/12/2023 and stated, “I only oversee the care for patients in the main location. I don’t have any interaction with the physician at that location.” The Medical Director assigned to the ADS was interviewed on 1/12/2023 and stated, “I don’t interact with the Medical Director of the other location, there are no phone calls or meetings. I can call if I need anything but never have.” The Alternate Administrator was interviewed on 1/12/2023 and stated, “I visit the ADS once a month to supervise but don’t have anything documented. I oversee both locations as Alternate Administrator and Director of Nursing. I am overwhelmed and realizing I need help.” Additionally, during interview on 1/12/2023, the Alternate Administrator agreed, there was no documented evidence the alternate delivery site shares supervision with the parent site. The Administrator was interviewed on 1/12/2023 and stated, "It was only a matter of time, we knew things weren't being done and we are trying to get help."

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met, as evidenced by interviews and personnel records review. 3 of 5 (60%) records of employees hired on or after July 17, 2020 reviewed, revealed the hospice did not ensure an initial orientation was provided. Record 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence of the initial orientation. Record 5 (Hospice Aide): hire date 5/5/2021. There was no documented evidence of the initial orientation. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence of the initial orientation. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the orientation checklist was completed. Record 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence of the initial orientation. Record 5 (Hospice Aide): hire date 5/5/2021. There was no documented evidence of the initial orientation. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence of the initial orientation. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the orientation checklist was completed.

It is required that the hospice assesses the skills and competencies of all individuals service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met, as evidenced by interviews and personnel records review. 1 of 2 (50%) records of registered nurses and hospice physicians hired on or after July 17, 2020 reviewed, revealed the hospice did not ensure a competency assessment was completed upon hire. Record 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence a competency assessment was completed upon hire. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence a competency assessment was completed. The Alternate Administrator stated, “this should have been done before the nurse was on her own; it’s missing.” Record 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence a competency assessment was completed upon hire. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence a competency assessment was completed. The Alternate Administrator stated, “this should have been done before the nurse was on her own, it’s missing.”

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met, as evidenced by a review of clinical records and interviews. 2 of 6 (33%) records reviewed, the hospice did not ensure initial certification requirements were completed. Record 5: The patient’s date of the election was 12/21/2022. There was no documented evidence of verbal and written initial certification from the medical director. Record 6: The patient’s date of the election was 11/8/2022. There was no documented evidence of verbal and written initial certification from the medical director. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence of a verbal and written certification in the records identified. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence of verbal and written initial certification from the medical director. Record 6: The patient’s date of election was 11/8/2022. There was no documented evidence of verbal and written initial certification from the medical director. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence of a verbal and written certification in the records identified.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met, as evidenced by a review of clinical records and interviews. 2 of 6 (33%) records reviewed revealed the hospice did not ensure the signed copies of the notice of patient rights and the hospice election statement were completed upon admission. Record 5: The patient’s date of the election was 12/21/2022. There was no documented evidence of signed copies of the notice of patient rights and the hospice election statement. Record 6: The patient’s date of the election was 11/8/2022. There was no documented evidence of signed copies of the notice of patient rights and the hospice election statement. The Alternate Administrator was interviewed on 1/12/2023 and stated, “I am not sure what happened to the consents.” The Alternate Administrator agreed there was no documented evidence of the signed copies of the notice of patient rights and the hospice election statement. Record 5: The patient’s date of election was 12/21/2022. There was no documented evidence of signed copies of the notice of patient rights and the hospice election statement. Record 6: The patient’s date of election was 11/8/2022. There was no documented evidence of signed copies of the notice of patient rights and the hospice election statement. The Alternate Administrator was interviewed on 1/12/2023 and stated, “I am not sure what happened to the consents.” The Alternate Administrator agreed, there was no documented evidence of the signed copies of the notice of patient rights and the hospice election statement.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period and no more than fifteen (15) days before the next benefit period begins. This standard was not met, as evidenced by clinical records review and interviews. 3 of 5 (60%) applicable records reviewed, the hospice did not ensure recertification requirements were completed. Record 1: The patient’s date of the election was 10/16/2020. There was no documented evidence of face-to-face encounter for the benefit period 2/8/2022-4/8/2022. There was no documented evidence of written recertification for the benefit period 2/8/2022-4/8/2022. Record 2: The patient’s date of the election was 10/16/2021. There was no documented evidence of face-to-face encounter for the benefit period 6/13/2022-8/11/2022. There was no documented evidence of face-to-face encounter for the benefit period 12/10/2022-2/7/2023. There was no documented evidence of written recertification for the benefit period 12/10/2022-2/7/2023. Record 3: The patient’s date of the election was 1/23/2022. There was no documented evidence of written recertification for the benefit period 4/23/2022-7/21/2022. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence of written certification and/or face-to-face encounter in the records identified. Record 1: The patient’s date of election was 10/16/2020. There was no documented evidence of face-to-face encounter for benefit period 2/8/2022-4/8/2022. There was no documented evidence of written recertification for benefit period 2/8/2022-4/8/2022. Record 2: The patient’s date of election was 10/16/2021. There was no documented evidence of face-to-face encounter for benefit period 6/13/2022-8/11/2022. There was no documented evidence of face-to-face encounter for benefit period 12/10/2022-2/7/2023. There was no documented evidence of written recertification for benefit period 12/10/2022-2/7/2023. Record 3: The patient’s date of election was 1/23/2022. There was no documented evidence of written recertification for benefit period 4/23/2022-7/21/2022. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence of written certification and/or face-to-face encounter in the records identified.

It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice: Are legally authorized (licensed, certified, or registered) in accordance with local, state, and federal law and regulation; Act only within the scope of their state license or state certification or registration; Keep their qualifications current at all times. This standard was not met, as evidenced by document reviews, interviews, and personnel records. 1 of 2 (50%) records reviewed of physicians, the hospice did not ensure the medical license was verified upon expiration. Agency policy, “Personnel Records, HR.11,” stated in part, “License or certification verification. When current licensure, certification, or registration are required by law or regulation to practice a profession, the organization verified these credentials at the time of hire and upon expiration of credentials.” Record 7 (Medical Director-EP): hire date 7/18/2022. There was no documented evidence the physician’s medical license was verified upon the expiration date of 11/30/2022. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence the physician's medical license was verified upon expiration. Agency policy, “Personnel Records, HR.11,” stated in part, “License or certification verification. When current licensure, certification, or registration are required by law or regulation to practice a profession, the organization verified these credentials at the time of hire and upon expiration of credentials.” Record 7 (Medical Director-EP): hire date 7/18/2022. There was no documented evidence the physician’s medical license was verified upon the expiration date 11/30/2022. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence the physician's medical license was verified upon expiration.

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of the COVID-19 vaccine or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment or other services for the hospice and/or its patients/families. Or there is evidence of an individual having a pending request for or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. This standard was not met, as evidenced by an interview and personnel records review. 5 of 8 (62%) records reviewed revealed the hospice did not ensure the employees were fully vaccinated for COVID-19 or had an approved exemption. Record # 1 (Administrator): hire date 10/1/2018. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption. Record #3 (Medical Director): hire date 1/31/2019. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption. Record # 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record # 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record #7 (Medical Director-EP): hire date 7/18/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. The Alternate Administrator was interviewed on 1/12/2023 and agreed there was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption in the records identified. Record 1 (Administrator): hire date 10/1/2018. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption. Record 3 (Medical Director): hire date 1/31/2019. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption. Record 4 (Registered Nurse-EP): hire date 2/17/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record 6 (Hospice Aide-EP): hire date 5/13/2021. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record 7 (Medical Director-EP): hire date 7/18/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. The Alternate Administrator was interviewed on 1/12/2023 and agreed, there was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption in the records identified.