Every finding on record at Rising Angels Palliative & Hospice LLC

It is required that each patient’s individualized written plan of care, includes all services necessary for the palliation and management of the terminal illness, including the following, intervention to manage pain and symptoms, and a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure the plan of care included a detailed statement of the scope and frequency of services necessary to meet patient and family needs. Agency policy 4: 4-027.1 The Plan of Care [reviewed April 2017] stated in part, "The written plan of care will contain, but will not be limited to, the following: Frequency/Amount/ Duration of services." Clinical Record 6: The patient elected the hospice benefit on 04/26/2023 with terminal diagnosis of end stage congestive heart failure. The revised/updated plan of care reviewed during the interdisciplinary group meeting dated 05/26/2023 included a frequency of visits for the skilled nurse but did not include frequency of visits for the medical social worker and chaplain who provided monthly visits to the patient. During an interview on 10/12/2023, the Director of Nursing stated the social worker and chaplain visit frequencies did get missed on the plan of care.

It is required that each patient’s individualized written plan of care, includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure the plan of care included drugs and treatments necessary to meet the patient’s needs. Agency policy 4: 4-027.1 The Plan of Care [reviewed April 2017] stated in part; "Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service. The written plan of care will contain, but will not be limited to, the following: drugs and treatments and individualized interventions to assist with end-of-life care." Clinical Record 2: The patient elected the hospice benefit on 07/24/2023 with a terminal diagnosis of end stage congestive heart failure. The initial comprehensive assessment identified the patient had constipation and the plan of care dated 07/24/2023 included an order for a Fleets enema daily as needed for constipation. The updated plans of care dated 09/05/2023 and 09/29/2023 did not include an order for the Fleets enema, and there was no documented evidence in the clinical record that the physician had discontinued the enema. During an interview the Director of Nursing stated that the plans of care medication lists were not accurate for the fleet's enema

It is required that a revised plan of care includes, information from the patient’s updated comprehensive assessment, and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure the plan of care was revised when there were changes documented in the comprehensive assessment. Clinical Record 2: The skilled nurse documented on the updated comprehensive assessment dated 08/28/2023, the patient was weaker and the oxygen saturation on room air was 82%. The nurse had the son apply oxygen, which the patient used at night. The patient’s oxygen saturation improved to 90% and the nurse instructed the patient/caregiver to use oxygen during the day. The interdisciplinary group reviewed the plan of care during the meeting dated 09/01/2023 but did not include the revision that the patient was now using oxygen during the day and at night, due to the lower oxygen saturation assessment. During review of findings on 10/12/2023, the Director of Nursing stated the interdisciplinary group was not updated of the patient's increased need for oxygen during the meeting.

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; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff followed agency policy when cleaning equipment. Review of the manufacturer directions for use of disinfectant wipes stated in part, "To disinfect: Use on hard, nonporous surfaces. Wipe surface to be disinfected. Use enough wipes for treated surface to remain visibly wet for 4 minutes. Let surface dry." Home Visit 3: During the home visit observation, the Registered Nurse obtained the patient’s vital signs. The nurse was observed to clean the equipment used to take the patient vital signs with disinfectant wipes. The thermometer, pulse ox, blood pressure cuff, and stethoscope were each cleaned with a separate disinfectant wipe and then placed into the nursing bag immediately after with no drying time. The nurse did not follow manufacturer directions when cleaning equipment to ensure effectiveness of the disinfectant wipe. During an interview on 10/12/2023, the Director of Nursing who performed the visit stated the time to dry would be completed in the future.

It is required that each patient's record includes at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure physician orders were documented in the clinical record. Clinical Record 2: The patient elected the hospice benefit on 07/24/2023 with a terminal diagnosis of end stage congestive heart failure. The initial comprehensive assessment identified the patient had constipation and the plan of care dated 07/24/2023 included an order for a Fleets enema daily as needed for constipation. The updated plan of care dated 09/05/2023 did not include an order for the Fleets enema, and there was no documented evidence in the clinical record that the physician had discontinued the enema. During an interview and review of findings on 10/13/2023, the Director of Nursing stated they would have to clarify if the Fleets enema is still being used.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by document review, interview and observation. In 2 of 3 (67%) home visits conducted in which a medication reconciliation was performed comparing the hospice agency's medication list to the medications being taken by the patient, it was revealed the hospice agency did not ensure an accurate and up-to-date medication profile was completed and included all medications in the medication review process. The agency's policy, "4-050.1 Medication Profile (revised April 2017)", stated in part" 2. "A Registered Nurse will perform a drug regimen review at the time of the initial and comprehensive assessment when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication... 3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen." Home Visit 2: During the home visit observation conducted on 5/17/2023, a medication reconciliation was completed comparing the hospice agency's medication profile (Record 3) to the medications taken by the patient. During interview, the patient reported he takes one (1) tablet of 325 mg of Aspirin each morning and review the medication profile in the clinical record revealed it did not contain an entry for Aspirin, 325 mg and Aspirin was not included in the review of the patient's medication regimen. In addition, the medication profile included an entry for, "Finasteride 5mg PO (orally) BID (two times daily)". The patient reported he does not take the medication Finasteride. Home Visit 3: During the home visit observation conducted on 5/17/2023, a medication reconciliation was completed comparing the hospice agency's medication profile (Record 1) to the medications taken by the patient. The hospice agency's medication profile contained an entry for: "Lorazepam 1 mg. Take one (1) tab PO (orally) every four (4) hours as needed for anxiety". Review of the patient's current in-home medication regimen revealed the patient was taking Lorazepam, 0.5 mg, one (1) tab by mouth every four (4) hours for anxiety, and the change is dosage was not updated in the clinical record. During a joint clinical record review and interview with the Director of Nursing (DON) on 5/17/2023, they confirmed the hospice agency's medication profiles were incorrect.

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. The IDG, in its entirety, supervises the care and services provided to the patient and family. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, clinical record review, and interviews which revealed the following issues with the organization's IDG membership and ability to provide services to meet all the needs of hospice patients: Failure of the hospice organization to include the Bereavement Coordinator/Chaplain as a participating member at the hospice IDT meetings [HCPC.2.D/L541/418.56(a)(1)(iv)]; and Failure of the hospice to offer to provide bereavement services to a patient's bereaved survivor [HCDT.22.I/L652/418.64(d)(1)(ii)]. The cumulative effect of these deficiencies could negatively impact the organization’s ability to ensure hospice services are planned, provided, and coordinated to will meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient and/or family facing terminal illness and bereavement.

It is required that the hospice Interdisciplinary Group includes, but is not limited to, individuals who are qualified and competent to practice in the following professional roles: Pastoral or other counselor(s). This standard was not met as evidenced by document review and interview. Review of the agency's Interdisciplinary Team (IDT) meeting notes and interviews with the Bereavement Coordinator/Chaplain, Alternate Administrator, and Social Worker revealed the hospice did not ensure that the Bereavement Coordinator/Chaplain was included as a participating member at the IDT meetings. During an interview conducted with the Bereavement Coordinator/Chaplain (Staff 3) on 5/18/2023, in the presence of the Alternate Administrator, review of the Bereavement Coordinator/Chaplain's role and responsibilities revealed the Bereavement Coordinator/Chaplain had not attended any of the bi-weekly IDT meetings to discuss patient care planning and interventions to address the patients' and families' identified physical, medical, psychosocial, emotional, and spiritual needs. The Bereavement Coordinator/Chaplain stated, "I do not attend IDT meetings. They have never let me know." In addition, review of the IDT meeting sign-in sheets revealed documentation of the Bereavement Coordinator/Chaplain's name and credentials as a meeting participant at 2 meetings, dated 4/28/2023 and 5/12/2023. The Bereavement Coordinator/Chaplain stated, "I have never signed that form because I have never been to an IDT." A subsequent interview was conducted on 5/18/2023, in the presence of the Alternate Administrator, with the Social Worker. The Social Worker confirmed the Bereavement Coordinator/Chaplain was not a participant at the Zoom Interdisciplinary Team (IDT) meeting on 5/12/2023. The Alternate Administrator was interviewed on 5/18/2023 regarding the documentation of the Bereavement Coordinator/Chaplain's name as a participant at the IDT meetings, and they confirmed that the Bereavement Coordinator/Chaplain was not present at the IDT meetings. They stated that a sign-in form template was photocopied, and the date of the meeting was entered, but the form was not edited to confirm which hospice staff were actually present for the meetings. The Alternate Administrator stated, "I won't use that form (signature template) anymore." Multiple interviews with the agency personnel revealed the agency did not include or invite all disciplines to the bi-weekly IDT meetings to discuss care planning of the patient and family's physical, medical, psychosocial, emotional, and spiritual needs identified by these members.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. This standard was not met as evidenced by record review and interview. Review of 1 of 1 (100%) applicable record of a patient who died while receiving hospice services revealed the hospice did not ensure bereavement counselling services were made available to family and other individuals as part of an organized bereavement services program. Clinical Record 5: The record for this patient with a hospice benefit election date of 9/17/2023 contained evidence of an initial bereavement assessment completed on 9/20/2022 that identified the patient "declined" bereavement services. The patient was discharged following their death on 4/1/2023 and the record did not contain any evidence of contact attempted or made with the primary bereaved individual identified in the initial assessment, to offer bereavement counselling services after the death of the patient. During an interview conducted with the Bereavement Coordinator/Chaplain (Staff 3) on 5/18/2023, in the presence of the Alternate Administrator, the Bereavement Coordinator/Chaplain confirmed it was the agency's policy to reach out to a primary bereaved individual following a patient's death, even though bereavement services were initially declined. The Bereavement Coordinator/Chaplain, "Yes, if someone initially declines the bereavement service, we still place a phone call within five (5) days to see if they want to reconsider the need". When asked if the Bereavement Coordinator/Chaplain had any documentation of reaching out to the patient's primary bereaved individual, the Bereavement Coordinator/Chaplain stated, "No, they (the patient) haven't died." When informed of the patient's date of death on 4/1/2023, the Bereavement Coordinator/Chaplain reported that they did not attend IDT meetings, stating, "They have never let me know". Interview with the Alternate Administrator confirmed the Bereavement Coordinator/Chaplain had not attended IDT meetings and bereavement services were not offered after the patient's (Record 5) death.

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) records it was revealed the hospice agency did not ensure all medications related to the management of the patient's terminal illness were provided to the patient while under hospice care. The agency's policy, "4-050.1 Medication Profile (revised April 2017)", stated in part, "(1) Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen. If the patient is enrolled in Medicare Part D, the nurse will review the medications with the patient or representative and determine the relationship of the medication to the patient's terminal illness and related conditions that contribute to the terminal prognosis. The nurse will designate medications as follows: (A). Related to terminal illness or related conditions (hospice pays for medication)". Clinical Record 2: The record for this patient documented a hospice benefit election date of 4/26/2023. The "Patient Notification of Non-Covered Items" form was dated as signed by the patient on 4/26/2023 and stated that all the medications and treatments related to the co-morbid diagnoses of "Chronic Systolic Congestive Heart Failure" and "Systemic Lupus” were related to the patient’s terminal condition and would be covered by the hospice agency. However, documentation of the medications, "Potassium CL 10 mEq", "Entresto 24-26mg" and “Clopidogrel 75 mg” on the medication profile dated 4/26/2023 included the statement “Insurance to pay", and it was not clear if the hospice was paying for these medications, which were related to the patient's diagnosis of "Chronic Systolic Congestive Heart Failure". During joint record review and interview with the Director of Nursing (DON)/Administrator on 5/16/2023, they confirmed that the hospice agency should be paying for the Potassium CL, Entresto, and Clopidogrel medications because the medications are standard treatments related to the diagnosis of chronic heart failure. The DON, who was also the admitting hospice nurse, said she believed the agency was paying "for all the patient's medications, and that is probably just an error on my part on the medication profile." An opportunity was provided for the agency to contact the pharmacy and present evidence that the hospice paid for the Potassium CL, Entresto, and Clopidogrel medications however, no additional evidence was provided for review prior to the end of the site visit.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) records reviewed where a patient was discharged from hospice services it was revealed that the agency did ensure that a copy of the discharge summary, including the medication profile and current physician orders as described in agency policy, was forwarded to the attending physician. The agency's policy, "4-076.1 Discharge from Hospice Program (revised April 2017)", stated in part: "Discharge Criteria... 5. The patient will be discharged if the patient revokes the hospice election... Procedure 3. When a patient is discharged, transferred, or referred to another organization, relevant information will include the reason for discharge, physical and psychosocial status at the time, including specific medical, psychosocial, or other problems requiring follow-up, a summary of the care provided and progress towards goals, a copy of the current Plan of Care, a copy of the medication profile, instructions and referrals provided to the patient." Clinical Record 4: The record for this patient documented a hospice benefit election date of 12/15/2022, with a terminal diagnosis of "Congestive Heart Failure", and a live discharge form dated 12/15/2022 that stated: "Pt revoked services. He decided to seek curative treatment at the hospital". The record did not contain evidence that a completed discharge summary, plan of care, and medication profile was sent to the patient's attending physician, as described in agency policy. During joint clinical record review and interview with the Director of Nursing/Administrator on 5/17/2023, they confirmed the attending physician was not sent a copy of the discharge summary, plan of care, and the medication profile.

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. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) records reviewed where a patient was discharged from hospice services it was revealed that the agency did not ensure a discharge summary was completed at the time of the patient's discharge from hospice services. The agency's policy, "4-077.1 Discharge Summary (revised April 2017)", stated in part: "1. Hospice personnel will complete a discharge summary at the time the discipline is discontinued, which will include: (A) the date of the discharge, (B) the reason for the discharge, including the name of where the patient is being transferred to, (C) Patient identifying information, (D) contact person receiving report with date and time report was given, (E) Patient's physician, (F) diagnosis related to discharge, (G) Significant health history, (H) Discharge orders, instructions, medication profile, and allergies...(M) A summary of the Care and services provided and the ongoing needs that cannot be met." Clinical Record 4: The record for this patient documented a hospice benefit election date of 12/15/2022, with a terminal diagnosis of "Congestive Heart Failure", and a live discharge form dated 12/15/2022 that stated: "Pt revoked services. He decided to seek curative treatment at the hospital". The record did not contain documented evidence that a discharge summary was completed that included a summary of the patient's hospice stay. During a joint record review and interview with the Director of Nursing/Administrator on 5/17/2023 they confirmed the record did not contain a completed discharge summary.