Every finding on record at Rx Staffing & Home Care, Inc.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the organization did not ensure the comprehensive assessment included an initial bereavement assessment. Clinical Record 2: The patient elected the hospice benefit on 10/02/2023. Review of the clinical record revealed no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. During an interview and review of the clinical record on 11/01/2024, the Clinical Quality Assurance Nurse stated that the patient's spouse refused spiritual care and bereavement services during the first five days of services and the bereavement assessment was not assigned to another clinician to complete.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by, the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with documented continuous care level of care, the organization did not ensure hospice care and services provided to the patient and family followed the plan of care established by the hospice Interdisciplinary Group [IDG]. Clinical Record 4: The patient was admitted to hospice services on 12/05/2023 with diagnoses of Alzheimer's Disease, adult failure to thrive, diastolic congestive heart failure, and right hip and sacral stage 4 pressure ulcers. Review of the clinical record revealed the patient's Registered Nurse Case Manager began documenting hourly entries on a visit note labeled as Continuous Care on 12/11/2024. The hourly entries ended on 12/12/2024 with the patient’s death. There was no documented evidence in the clinical record that the physician ordered continuous care services and no documented evidence that the plan of care was updated for continuous care services. During an interview and review of the clinical record on 11/01/2024, the Clinical Quality Assurance Nurse confirmed the patient's plan of care was not updated by the hospice IDG to change the patient's level of care from routine to continuous care on 12/11/2024. The nurse stated, "There is no physician's order to update the plan of care to continuous care, but the RN provided and documented continuous care."

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 10 (10%) clinical records reviewed with nursing supervision required, the organization did not ensure the Registered Nurse (RN) provided nursing supervisory assessments as required by agency policy. The organization’s policy on nursing supervision revised 09/15/2021 required in part, "Licensed Vocational/Practical Nurses shall have a current LVN/LPN license, at least one (1) year experience as a licensed nurse, and shall work under the supervision of a Registered Nurse. Supervision shall occur no less than every 30 days." Clinical Record 5: The patient elected the hospice benefit on 02/05/2024 with benefit period 4 effective 10/04/2024 to 11/30/2024. Clinical record review revealed the RN documented an LVN supervisory assessment on 09/10/2024. The next LVN supervisory assessment was dated 10/28/2024, a total of 48 days and 18 days outstanding. During an interview and review of the clinical record on 11/01/2024, the Clinical Quality Assurance Nurse confirmed the RN completed the LVN supervisory assessments 48 days apart.

It is required that hospice aides are supervised by a Registered Nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 3 of 11 (27%) clinical records reviewed with aide services provided for more than 14 days, the organization did not ensure the Registered Nurse (RN) documented aide supervisory assessments no less frequently than every 14 days. Clinical Record 2: The patient elected the hospice benefit on 10/02/2023. Clinical record review revealed aide services were effective 10/06/2023. The RN documented an aide supervisory assessment on 10/12/2023 and the next aide supervisory assessment was dated 10/27/2023, a total of 15 days and 1 day outstanding. Clinical Record 5: The patient elected the hospice benefit on 02/05/2024. Clinical record review revealed aide services were effective 10/04/2024. The RN documented an aide supervisory assessment on 09/24/2024 and the next aide supervisory assessment was dated 10/22/2024, a total of 28 days and 14 days outstanding. Clinical Record 6: The patient elected the hospice benefit on 06/11/2024. Clinical record review revealed aide services were effective 09/09/2024. The RN documented an aide supervisory assessment on 09/17/2024 and the next aide supervisory assessment was dated 10/02/2024, a total of 15 days and 1 day outstanding. During an interview and review of the clinical records on 11/01/2024, the Clinical Quality Assurance Nurse confirmed the RN did not document aide supervisory assessments every 14 days.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The organization did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent of the total patient care hours of all paid hospice employees and contract staff. During a concurrent interview and review of the agency binder titled Volunteer Program with the Administrator/Volunteer Coordinator on 11/01/2024, it was revealed that the organization did not provide volunteer services in 2023 and in 2024. The Administrator provided his documented efforts to recruit volunteers after the end of the public health emergency in May of 2023, and explained they were not successful until April of 2024 when two volunteers were hired. The calculation of volunteer time cost savings presented by the Administrator calculated from April 2024 through October 2024 was 0.6%. During a concurrent interview and review of the binder titled Volunteer Program with the Administrator/Volunteer Coordinator on 11/01/2024, it was revealed that the organization did not provide volunteer services at all in 2023 and in 2024 did not provide volunteer services that at minimum equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Administrator revealed that his documented efforts to recruit volunteers after the end of the public health emergency in May of 2023, were not successful until he hired two volunteers in April of 2024. The calculation of volunteer time cost savings presented by the Administrator calculated from April 2024 through October 2024 was 0.6%.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed for patients that reside in an SNF [Skilled Nursing Facility], the organization did not ensure the hospice plan of care specified which provider was responsible for performing the functions agreed upon and included in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 10/02/2023. The patient resided in an SNF. The hospice plan of care did not identify which provider was responsible for performing care and services agreed upon and included in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 06/13/2024. The patient resided in an SNF. The hospice plan of care did not identify which provider was responsible for performing care and services agreed upon and included in the plan of care. Clinical Record 11: The patient elected the hospice benefit on 08/16/2024. The patient resided in an SNF. The hospice plan of care did not identify which provider was responsible for performing care and services agreed upon and included in the plan of care. Clinical Record 14: The patient elected the hospice benefit on 09/28/2024. The patient resided in an SNF. The hospice plan of care did not identify which provider was responsible for performing care and services agreed upon and included in the plan of care. During the daily wrap-up conference on 10/31/2024, the Administrator stated, "Our contract with the SNFs includes an addendum listing the delineation of responsibilities between us and them, but I agree that our patient plans of care do not include whether it is the hospice, the SNF, or both that are specifically providing specific functions included in individual patient plans of care."

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 an interview with the Quality Assurance (QA) RN and a review of agency binders titled QAPI 2019, QAPI 2020, and QAPI 2021. Reports, clinical record audits, and minutes of QAPI meetings did not include documented evidence of remedial actions taken (i.e., staff education or analysis of targeted clinical record reviews) with subsequent measurable outcomes. There was no evidence documented that the agency was monitoring identified performance concerns to ensure improvements or sustained improvements in quality issues identified in Quarters 3 and 4 of 2019, 2020, or 2021. The Binder titled QAPI 2019 under the tab labeled Quarter 3 contained a documented quarterly meeting that included data collected in the form of chart audits, pain assessments, infection reports, incident reports, complaints, and HIS admission and discharge indicators. There was no analysis of this data, and no performance issues were identified. No performance improvement plans (PIPs) were initiated. Under the tab labeled Quarter 4, a document titled “Fourth Quarter QAPI Meeting Minutes” documented on May 7, 2020, states in part, “We want to develop a PIP plan. …based on the audit tool chosen, we can determine what we wanted to achieve in 2020.” Binder titled QAPI 2020 contained a sign-in sheet titled “QAPI Meeting First, Second, and Third Quarters” documented as having taken place on 12/23/2020. The binder includes audit tools for HHA Care Plan and RN supervisory visits but no analysis of the data collected in these audits. Binder titled QAPI 2021 included clinical record review tools under tabs labeled Quarters 1-3 but no analysis of data collected using these tools. There were documented PIPs under a tab labeled “QTR 4” with initiation dates of 9/2021 titled Fall Tracking, Infection Control, Measurable Goals, Initial Plan of Care, Visit Frequency, and Bereavement Program. All documented PIPs include a specified goal, how the problems were identified, how the problem related to the organization's mission, what the implementation of a PIP should accomplish, possible solutions, and data needed for review. For example, the Bereavement Program PIP indicates that a problem was identified as “Lack of complete initial bereavement assessment and ongoing bereavement program documentation by the interdisciplinary hospice group.” The specified goal is to “meet compliance of initial plan of care to 100% of each quarter for two (2) consecutive quarters”. Possible solutions are to “educate hospice staff on comprehensive documentation and care planning” and “100% audit of all admissions and deaths each quarter”. There was no documented evidence of bereavement education provided to staff identified as responsible for completing bereavement assessments or bereavement plans of care. There was evidence of one (1) clinical record review form completed in September 2021 but no data analysis.

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. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records and interview. In 2 of 2 (100%) death records reviewed there was no documented attempt to assess for or initiate a bereavement plan of care after patient death. In interview, the Bereavement Coordinator indicated that he was contacting patient family members to offer support and sends supportive mailings. He stated that these interactions were not based on a bereaved-specific, documented plan of care. Record #82674: Start of Care (SOC)12/1/2021, 1st Benefit Period, Diagnosis CVA/Stroke, Date of Death 12/2/2021: In an interview, the Bereavement Coordinator stated that he was not made aware of the patient’s admission and death to attempt to complete an assessment of identified bereaved or to initiate a bereavement plan of care. Record #77790: SOC 12/30/2021, 1st Benefit Period, Diagnosis CA of Prostate, Date of Death 12/30/2021 (same day): In an interview, the Bereavement Coordinator stated that both he and a Medical Social Worker (MSW) spoke to the patient’s family before and after the patient’s death but did not develop a bereavement plan of care based on a bereavement assessment.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 41.I; and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 1 (100%) record that included a patient transfer to a Medicare/Medicaid certified facility, there was no documented evidence that a copy of a hospice discharge summary was provided to the receiving facility. Record #36383: Start of Care (SOC) 4/29/2021, 1st Benefit Period, Diagnosis Protein Calorie Malnutrition, Transfer to Hospital 6/12/2021: During joint clinical record review with the QA RN, it was revealed that there was no summary sent to the receiving facility 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; or patient/family concerns involving possible neglect of the patient. This finding was confirmed by the Office Manager, who would have been assigned to fax this documentation to the hospital.

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 a review of clinical records and interview. 7 of 7 (100%) discharged records did not include a documented hospice discharge summary that included all required elements. Record #57789, Start of Care (SOC) 2/10/2021, 3rd Benefit Period, Diagnosis Cerebral Atherosclerosis, Date of Revocation 8/23/2021. Record #82674, SOC 12/1/2021, 1st Benefit Period, Diagnosis CVA/Stroke, Date of Death 12/2/2021. Record #69695, SOC 8/19/21, 1st Benefit Period, Diagnosis Inclusion body myositis, Date of Discharge for extended prognosis 11/10/2021. Record #95164, SOC 12/16/2020, 2nd Benefit Period, Diagnosis CA of Head, Face, and Neck, Date of Revocation 6/3/2021. Record #77790, SOC 12/30/2021, 1st Benefit Period, Diagnosis CA of Prostate, Date of Death 12/30/2021 (same day). Record #15524, SOC 2/2/2021, 2nd Benefit Period, Diagnosis Cerebral Atherosclerosis, Date of Discharge for extended prognosis 6/29/2021. Record #36383, SOC 4/29/2021, 1st Benefit Period, Diagnosis Protein Calorie Malnutrition, Date of transfer/discharge to hospital 6/12/2021. The QA RN stated that she had observed this finding in clinical record reviews conducted by agency staff.