Every finding on record at Sahara Hospice Care LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the IDG team completed an initial assessment no later than 5 days after the election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 08/09/2024 with a diagnosis of Vascular Dementia. There was no social work visit documented in the clinical record. Upon further review of the record there was no documented evidence of an initial psychosocial assessment and not documentation explaining why the visit was not competed. An internal audit was conducted by a consultant where this issue was identified, and a performance improvement plan has been initiated with follow up from the consulted to occur on 09/03/2024, 09/17/2024, and 10/08/2024.

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 5 (20%) clinical records reviewed revealed that the agency did not ensure that a plan of care was written by the IDG group. Clinical Record 2: The patient elected the hospice benefit on 08/09/2024 with a diagnosis of Vascular Dementia. The Director of Nursing stated that on admission a plan of care was written as if a doctor's order and sent to the doctor for signature, then the plan of care is generated at the first IDG meeting after admission. This should have taken place on 08/26/2024. During review of the clinical record there was no documented evidence of a plan of care or IDG meetings completed. The director of nursing stated that the EMR has been having some issues and making updates that have affected some documentation to show up. She stated that she and the consultant are working with EMR vendor to resolve these issues.

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. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the IDG group did not review, revise, or document the individualized care plan no less frequently than every 15 days or as the patient's condition requires it. Clinical Record 1: The patient elected the hospice benefit on 08/19/2024, with a diagnosis of Alzheimer's Disease. The clinical record review revealed documented evidence of a care plan and an IDT meeting on the same date. However, no further documentation of any subsequent IDT meetings or updated care plans was found. In an interview, the Director of Nursing indicated that documentation from an IDT meeting held on 08/30/2024, should be present in the record, yet no such documentation was located. Clinical Record 2: The patient elected the hospice benefit on 08/09/2024. During review of the clinical record there was no documented evidence of an IDT meeting taking place for this patient. In an interview with the director of nursing, she stated their IDG meeting took place on 08/16/2024 and 08/30/2024 with the next one due on 09/13/2024. She was unable to provide the documentation for 08/16/2024 or 08/30/2024.

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. In 1 of 4 (25%) clinical records reviewed revealed that the agency did not ensure specific instructions were included on the aide plan of care. Clinical Record 1: The patient elected the hospice benefit on 08/19/2024 with a diagnosis of Alzheimer's disease. The patient had aide services ordered on the plan of care for 3 times a week. The plan of care developed and written by the RN included as needed tasks for foot care, back rub, nail care, partial bath or shower, shave, assist with bedpan and assist with bedside commode. The aide care plan lacked specific instructions for the aide. Clinical Record 3: The patient elected the hospice benefit on 08/20/2024 with a diagnosis of Alzheimer's disease. The plan of care ordered aides 5 times a week. The plan of care developed and written by the RN included as needed tasks for foot care, back rub, nail care, partial bath or shower, shave, light housekeeping, assist with bedpan and assist with bedside commode. The aide care plan lacked specific instructions for the aide. During the joint record review and interview with the clinical manager, she said they did use the as needed orders.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. The 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 record reviewed revealed that the agency did not ensure that the clinical record included physician orders. Clinical Record 2: The patient elected the hospice benefit on 08/09/2024 with a diagnosis of Vascular Dementia. On the initial RN comprehensive assessment, the RN documented assessment of wounds and wound care completed, "On the left buttock area, the patient has some scattered stage 2 pressure injuries. SN cleansed the area with normal saline and applied hydrocolloid dressing over it. The skin tear on the left elbow measures 2 cm X 1.0 cm X 0.1 cm and the right-hand skin tear measures 1.5 cm X 1.0 cm X 0.1 cm. SN cleansed the area with the normal saline, applied triple antibiotic and covered with foam dressing. Patient tolerated it well." During further review of the clinical record there was no evidence of a physician's order for wound care. In an interview with the director of nursing she stated the order should have been in the chart or listed on the plan of care.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record of a discharged patient revealed that the agency did not ensure that the discharge summary or patients record was forwarded to the receiving facility. THIS IS A CONTINUED REQUIRED ACTION Clinical Record 5: The patient elected the hospice benefit on 08/21/2023 with a diagnosis of Alzheimer's Disease. On 08/29/2024 the family made the decision to revoke hospice services due to the patient was sent to the hospital for aggressive treatment. There was no documented evidence that the agency made any communication with the hospital or that a discharge summary had been sent. During the interview with the director of nursing she stated that the patient went to the hospital for IV antibiotics, and she could not provide any documentation that report was called or that any documents were sent to the receiving facility. THIS IS A CONTINUED REQUIRED ACTION

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following, a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record that was discharged revealed that the agency did not ensure that a discharge summary was completed. THIS IS A CONTINUED REQUIRED ACTION Clinical Record 5: The patient elected the hospice benefit on 08/21/2023 with a diagnosis of Alzheimer's Disease. On 08/29/2024 the family made the decision to revoke hospice services due to the patient was sent to the hospital for aggressive treatment. There was no documented evidence that the agency completed a discharge summary including 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 requested. In an interview with the director of nursing she was unable to provide documentation of a discharge summary for this patient. During the interview with the director of nursing she stated that the patient went to the hospital for IV antibiotics, and she could not provide any documentation that report was called or that any documents were sent to the receiving facility. THIS IS A CONTINUED REQUIRED ACTION

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. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by document review, interview and observation. In 2 of 14 (14%) medication profiles for active hospice patients reviewed revealed that the hospice agency did not ensure that the patient's drug profile contained the patient's current prescription and over-the-counter drugs. The hospice agency did not ensure the patient's drug profile was updated per the hospice policy and procedure. Document 2: Policy 8.20.1 (Revised June 2019), titled, Medication Reconciliation, stated in part, medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list will be updated with each new or changed medication. Home Visit 1: The hospice election of benefit was 04/19/2023 and the patient resided in an assisted living facility (ALF). During the home visit (Home Visit 1, Clinical Record 1) with the Chaplain (Personnel Record 7) on 07/25/2024 the medication profile was reviewed. The agency medication profile listed an Acetaminophen rectal suppository of 650 mg per rectum every six hours as needed for pain and Lorazepam oral 0.5 mg every 2-3 hours as needed for anxiety. The medications were ordered on 12/15/2022. The Acetaminophen and Lorazepam was not listed on the facility medication profile. Home Visit 2: The hospice election of benefit was 04/01/2024 and the patient resided in an assisted living facility (ALF). During the home visit (Home Visit 2, Clinical Record 2) with the registered nurse (RN) (Personnel Record 6) on 07/25/2024, The hospice medication profile reviewed on 07/25/2024 listed Lasix oral 20 mg daily at 9 am. The medication was ordered on 07/02/2024. The hospice medication profile listed Atropine Sulfate Ophthalmic Solution 1% give one drop under the tongue once daily as needed and Rytary oral extended release 48.75-195 mg at 8 am, 12 pm, 4 pm, and 8 pm. Both the Atropine and Rytary were ordered on 06/21/2024. The Lasix, Atropine, and Rytary medications were not listed on the facility medication profile. During an interview on 07/25/2024, the Director of Nursing agreed the medication profiles has not been reconciled.

It is required that Volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by a review of clinical records, document review, and interview which revealed the hospice: Failed to ensure the patients had a volunteer needs assessment, and volunteer plan of care with task for the volunteers to perform {HCDT.21. I/L644}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: Noted in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 4 (50%) clinical records reviewed for patients receiving volunteer services revealed that the hospice agency did not ensure the patients had a volunteer needs assessment, and volunteer plan of care with task for the volunteers to perform. Document 2: Agency 4.24.3., titled, Volunteer Services, stated in part, volunteer duties may include patient care activities that must be evident in the patient's plan of care. Patient care activities allowed are emotional support, companionship and practical assistance, errands, meals, housekeeping tasks, and minimum patient comfort measures and transportation. Clinical Record 1: The patient elected the hospice benefit on 04/19/2023. Volunteer services were ordered on 05/13/2024 at a frequency of once a quarter. The patient received volunteer visits on 05/16/2024 and 05/30/2024. The patient volunteer documented that the patient's nails were cut, new colors polished, and massaged hands. There was no documented evidence that the volunteer coordinator completed a volunteer needs assessment, no volunteer assigned task for the volunteer to complete on the patient volunteer visits and was not included in the plan of care. Clinical Record 2: The patient elected their hospice benefit on 04/01/2024. Volunteer services were ordered on 04/01/2024 at a frequency of one time a month. The patient has received volunteer visits on 04/09/2024 and 06/04/2024. The patient volunteer documented that the patient's nails were cut and massage oil was applied to the patient's arms and legs. There was no documented evidence that the volunteer coordinator completed a volunteer needs assessment, no volunteer assigned task for the volunteer to complete on the patient volunteer visits and was not included in the plan of care. During an interview on 07/26/2024, the Administrator/Volunteer Coordinator agreed that the patient volunteer had been cutting the patient's nails as documented in the clinical records. The Administrator/Volunteer Coordinator also stated he would be educating the patient volunteer on what allowable tasks a patient volunteer may perform with the patients.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical records reviewed for patients transferred to another Medicare/Medicaid-certified facility revealed that the hospice agency did not ensure a copy of the hospice discharge summary was forwarded to the receiving Medicare/Medicaid-certified facility. Document 3: Policy 9.29.1 (Revised 2019), titled, Discharge Summary, stated in part, if the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice will forward, to the receiving facility, a copy of the hospice discharge summary. Clinical Record 12: The patient elected their hospice benefit and start of care on 08/18/2023. The patient was discharged from the hospice agency due to transferring to Medicare/Medicaid certified facility on 09/26/2023. The clinical record included a documented live discharge note dated 09/26/2023. There was no documented evidence that a hospice discharge summary was completed and forwarded to the receiving facility, During an interview on 07/26/2024, the Director of Nursing agreed that a discharge summary had not been completed or forwarded to the receiving facility. The Director of Nursing stated that the receiving facility transferred the patient without them being made aware until a week later.

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 1 (100%) clinical records reviewed for patients discharge revealed that the hospice agency did not ensure that the hospice discharge summary was completed and included a summary of the patient's hospice stay, including treatments, symptoms, and pain management. Document 2: Policy 9.29.1 (Revised June 2019), titled, Discharge Summary, stated in part, that the hospice discharge summary will include a summary of the patient's stay including treatments, symptoms, and pain management. Clinical Record 12: The patient elected their hospice benefit and start of care on 08/18/2023. The patient later transferred to another hospice on 09/26/2023. There was no documented evidence that the hospice discharge summary had been completed. During an interview on 07/26/2024, the Director of Nursing agreed that the hospice discharge summary had not been completed.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including: conducting ongoing interdisciplinary comprehensive assessments; developing and evaluating the plan of care; contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by personnel record and clincial record reviews, and interviews with the Administrator. The hospice failed to ensure that medical social work, and counseling core services were provided directly by hospice employees [HCDT.2.I/L588]; The cumulative effect of these issues have resulted in the hospice’s inability to ensure the provision of quality health care in a safe environment. The deficient practices illustrated process failures that had the potential to affect all patients cared for by the agency.

It is required that a hospice must routinely provide substantially all core services directly by hospice employees. These services must be provided in a manner consistent with acceptable standards of practice. These services include nursing services, medical social services, and counseling. This standard was not met as evidenced by a review of document reviews, interviews and personnel records. In 5 of 5 (100%) personnel records reviewed of social worker and spiritual counselor revealed the hospice did not ensure to routinely provide substantially all core services directly by hospice employees.. Record 1: (Chaplain): hire date 12/2/2022. Review of the personnel file revealed the Chaplain was contracted to provide counseling services to the hospice with a completed W-9. Record 4: (Chaplain): hire date 4/1/2022. Review of the personnel file revealed the Chaplain was contracted to provide counseling services to the hospice with a completed W-9. Record 5: (Chaplain): hire date 4/1/2022. Review of the personnel file revealed the Chaplain was contracted to provide counseling services to the hospice with a completed W-9. Record 6: (Social Worker): hire date 10/10/2022. Review of the personnel file revealed the Social Worker was contracted to provide social services to the hospice with a signed independent contractor agreement and completed W-9. Record 7: (Social Worker): hire date 4/4/2022. Review of the personnel file revealed the Social Worker was contracted to provide social services to the hospice with a completed W-9. The Administrator was interviewed on 12/12/2022 and stated, “the chaplain and social workers are not direct employees, they are all contracted, it doesn’t make sense to hire with our census.” The Administrator stated, “I didn’t realize they couldn’t all be contracted, we started the process today to change two of the chaplains to direct employees, not contract.” The Human Resources Manager was interviewed on 12/12/2022 and stated, “there are no W-4, no taxes taken out, for the social workers and chaplains.” Record 1: (Chaplain): hire date 12/2/2022. Review of the personnel file revealed the Chaplain was contracted to provide counseling services to the hospice with a completed W-9. Record 4: (Chaplain): hire date 4/1/2022. Review of the personnel file revealed the Chaplain was contracted to provide counseling services to the hospice with a completed W-9. Record 5: (Chaplain): hire date 4/1/2022. Review of the personnel file revealed the Chaplain was contracted to provide counseling services to the hospice with a completed W-9. Record 6: (Social Worker): hire date 10/10/2022. Review of the personnel file revealed the Social Worker was contracted to provide social services to the hospice with a signed independent contractor agreement and completed W-9. Record 7: (Social Worker): hire date 4/4/2022. Review of the personnel file revealed the Social Worker was contracted to provide social services to the hospice with a completed W-9. The Administrator was interviewed on 12/12/2022 and stated, “the chaplain and social workers are not direct employees, they are all contracted, it doesn’t make sense to hire with our census.” The Administrator stated, “I didn’t realize they couldn’t all be contracted, we started the process today to change two of the chaplains to direct employees, not contract.” The Human Resources Manager was interviewed on 12/12/2022 and stated, “there are no W-4, no taxes taken out, for the social workers and chaplains.”

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 of participation was not met as evidenced by a review of clinical records and interviews with the Director of Nurses which revealed issues with completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to ensure that the patient/caregiver was assessed for psychosocial and spiritual services no later than five days after the election of hospice care [HCPC.9.I/L523]; failure to conduct an initial bereavement risk assessment [HCPC.13.I/L531]; failure to ensure that patients were assessed for, and offered medical social work services [HCDT.9.I/L594]; and failure to ensure the patient/family needs for spiritual counseling services were assessed and reasonable efforts were made to provide spiritual counseling [HCDT.11.I/598]. 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 Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed of patients electing hospice care after 9/27/2022, revealed the hospice did not ensure that the patients/caregivers were assessed for psychosocial and spiritual services no later than five days after the election of hospice care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. Clinical Record 3: was reviewed and identified the patient elected hospice care on 10/21/2022. Review of the clinical record revealed no evidence that an initial spiritual care comprehensive assessment and the psychosocial portion of the initial comprehensive assessment were completed within 5 days of the date of election as required, and as of 11/09/2022. There was no evidence the psychosocial or spiritual assessment were offered and /or refused. Clinical Record 2: was reviewed and identified the patient elected hospice care on 10/19/2022. Review of the clinical record revealed the patient was seen by the Social Worker on 11/2/2022, 15 days after the patient elected hospice care. There was no evidence an initial spiritual care comprehensive assessment was completed as of 11/9/2022. There was no evidence that the initial spiritual care comprehensive assessment and the psychosocial portion of the initial comprehensive assessment were completed within 5 days of the date of election. During an interview on 11/9/2022, the Director of Nursing confirmed that the psychosocial and spiritual Assessments were not completed within five days of the election of hospice care. No further information was provided.

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 IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed of patients electing hospice care after 9/27/2022 revealed that the hospice did not ensure completion of an initial bereavement risk assessment. Clinical Record 2 The patient was admitted on 10/21/2022 with a diagnosis of malignant Neoplasm. there is no documentation of an initial bereavement risk assessment of the needs of the patient's family and other individuals, focusing on social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. During an interview on 11/09/2022, the Director of Nursing confirmed that an initial bereavement assessment was not completed on admission. No further information was provided.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, and under the direction of a physician. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, and family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed of patients electing hospice care after 9/27/2022 revealed the hospice did not ensure that the patient/caregiver was assessed and offered psychosocial services. Clinical Record 3: The patient elected hospice care on 10/19/2022. Review of the clinical record revealed no documented evidence that medical social worker services were offered and or refusal as of 11/09/2022. Clinical Record 2: The patient elected hospice care on 10/19/2022. Review of the clinical record revealed no documented evidence that medical social worker services were offered and or refusal as of 11/09/2022. During an interview on 11/09/2022, the Director of Nursing confirmed that the psychosocial assessments were not offered. No further information was provided.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) clinical records reviewed of patients electing hospice care after 9/27/2022 revealed the hospice did not ensure that the patient/family was offered spiritual counseling services and reasonable efforts were made to provide spiritual counseling. Clinical Record 3: The patient elected the hospice care on 10/19/2022. Review of the clinical record revealed no evidence that the hospice assessed, offered and/or provided spiritual counseling. There was no evidence the patient refused spiritual care as of 11/09/2022. Clinical Record 2: The patient elected the hospice care on 10/19/2022. Review of the clinical record revealed no evidence that the hospice assessed, offered and/or provided spiritual counseling. There was no evidence the patient refused spiritual care as of 11/09/2022. During an interview on 11/09/2022, the Director of Nursing (DON) confirmed that spiritual counseling services was not assessed, offered, or provided. No further information was provided.

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 a review of personnel records, interviews and document reviews. 5 of 7 (71%) personnel records reviewed of individuals providing care, hired after 9/27/2022, revealed that the agency did not ensure that competencies assessed upon hire. The agency's policy # 4.28.1, stated in part, " Patient care staff will be competency assessed at defined intervals...For each new employee (including contracted employees) during orientation." Staff 7: The personnel record of the Director of Nursing (DON) hired on 08/18/2022 was reviewed and revealed no competencies were assessed upon hire. Staff 5: The personnel record of the (LVN) Licensed Vocational Nurse hired on 10/03/2022 was reviewed and revealed no competencies were assessed upon hire. Staff 4: The personnel record of the (CNA) Certified Nursing Assistant hired on 10/19/2022 was reviewed and revealed no competencies were assessed upon hire. Staff 3: The personnel record of the (RN) Registered Nurse hired on 10/03/2022 was reviewed and revealed no competencies were assessed upon hire. Staff 2: The personnel record of the (MSW) Medical Social Worker hired on 10/20/2022 was reviewed and revealed no competencies were assessed upon hire. Staff 1: The personnel record of the RN hired on 10/13/2022 was reviewed and revealed no competencies were assessed upon hire. The DON was interviewed on 11/08/2022. She confirmed that competencies of individuals including contract employees that are providing care were not assessed upon hire. No further information was provided.

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 primary terminal condition, related diagnosis(es), if any; current subjective and objective medical findings, current medication and treatment orders. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed of patients with a certification occurring after 9/27/2022 revealed the hospice did not ensure that the certification statement was completed by the Medical Director as required. Clinical Record 1: was reviewed and identified the patient elected hospice care on 10/15/2022. Review of the record revealed no evidence of a verbal certification and the certification statement was not completed by the Medical Director. The narrative statement was copied from the initial assessment completed by a Registered Nurse (RN). The form did not include evidence of the date of the certification benefit period, the current subjective and objective medical findings, the current medications and the treatments. The certification statement read in part " Referral received for hospice care, met patient at the bedside and a head to toe assessment was completed." The Medical Director's signature did not include the date. During an interview on 11/9/2022, the Director of Nursing confirmed that the Initial Certification was incomplete and was not written by the Medical Director, but was copied from the RN's initial assessment. No further information was given.

It is required that policies and procedures define the complaint/grievance management process and include: Designation of staff responsible for managing the complaint process; Procedures and timeframes for documented intake and investigation; Documented status of the complaint, including resolution (if any); Corrective action taken (if necessary); What information, if any, is shared with the complainant. This standard was not met as evidenced by a review of document reviews and interviews. The hospice did not ensure that the agency had a process in place to receive and investigate complaints. The Administrator failed to provide documentation of patient/ family member complaints for the previous 12 months. This was to include how the hospice received, recorded, investigated, and resolved these complaints. There was no documented evidence of a complaint policy or process. The Administrator and the DON were unable to describe how the hospice received, recorded, investigated, and resolved these complaints.They could describe how a complaint investigation was conducted when a patient/family made a complaint. The Administrator and DON failed to provide the documentation of patient and family complaints or the complaints log for the previous 12-month period. In an interview on 9/27/2022, the Director of Nurses (DON) and the Administrator the DON stated that she” would look for the book”. The DON did not return, and the Administrator stated, "She is on the phone with a patient is not available." Upon entrance to the agency, request was made to provide documentation of complaints made by patients, or patient families for the previous 12 months. This was to include how the hospice received, recorded, investigated, and resolved these complaints. In an interview with the Director of Nurses and the Administrator on 9/27/2022, the Director of Nurses stated that she” would look for the book” and could not provide evidence of how a complaint investigation was conducted when a patient/family makes a complaint. This includes the activities and processes of a staff member, who is accountable for receiving, investigating and resolving any patient concerns. The Director of Nurses did not return, and the Administrator stated, "She is on the phone with a patient is not available."

It is required that the hospice conducts and documents a patient-specificcomprehensive 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 of participation was not met as evidenced by review of clinical records and interview with the Director of Nurses and the Administrator which revealed issues with completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to demonstrate completion of the 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 to conduct patient specific comprehensive assessments [HCPC.7.I/L521]; failure of the comprehensive assessment to address the psychosocial and spiritual needs HCPC.10.I/L524]; and failure to conduct 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 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 standard was not met as evidenced by a review of clinical records and interviews. 5 of 6 (83%) of records reviewed revealed that the hospice did not ensure the comprehensive assessment upon admission identified the patient's care needs and services. There was no documented evidence that thesocial work and chaplain services had been offered or refused. [Record #1, 2, 3, 4, and 6.] In an interview with the Administrator and the Director of Nursing, it was stated, "We only provided nursing and physician services." .

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 6 (83%) of records reviewed revealed that the hospice did not ensure that the initial spiritual care comprehensive assessment and the psychosocial portion of the initial comprehensive assessment were completed within 5 days of the date of election as required. [Record #1, 2, 3, 4, and 6]. During an interview on 9/27/2022, the Administrator stated, "I was not aware of this requirement." .

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s: Well-being; Comfort, [and] dignity throughout the dying process. This standard was not met as evidenced by a review of document reviews and interviews. In 5 of 6 (83%) of records reviewed revealed that the hospice did not ensure the comprehensive assessments addressed the psychosocial and/or spiritual needs. There was no documented evidence that the psychosocial and spiritual needs were addressed throughout the course of care by the patients served. [Records #1, 2, 3, 4, and 6]. In an interview with the Administrator, on 9/27/2022, it was stated, "I was not aware that the assessments had to include the psychosocial and spiritual services. I have talked to a consultant who informed me that they must be included." .

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 a review of clinical records and interviews. 5 of 6 (83%) of records reviewed revealed that the hospice did not ensure completion of the Grief Risk Assessment at the time of admission. [Record #1, 2, 3, 4, and 6.] In an interview with the Administrator, on 9/27/2022, it was stated " I was not aware that the Bereavement Risk Assessment was required when admitted”.

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. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 6 (83%) of records reviewed revealed that the hospice did not ensure the Psychosocial (LMSW) and Spiritual (Chaplain) attended the Interdisciplinary Group, assisted with the written Plan of Care, under the auspices of the patient's Physician. Record #1, 2, 3, 4, and 6. In an interview with the Administrator on 9/27/2022, it was stated, "I was not aware that the Chaplain and the LMSW were part of this process. I have hired a consultant and she has not been able to come to the agency." .

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 standard was not met as evidenced by a review of clinical records and interviews. In 5 of 6 (83%) of records reviewed revealed that hospice did not ensure that the Interdisciplinary Group provided documented evidence of team members providing Psychosocial, Spiritual and Bereavement need or supervision to ensure patient/family care and services. Record #1, 2, 3, 4, and 6. In an interview with the Administrator, it was stated that the LMSW and the Chaplain” had never attended IDG and had not seen any of the patients”, as he had taken ownership on 4/1/2022. The stated that he” had talked to a consultant and had been instructed to provide Chaplain and LMSW services”.

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 a review of clinical records and interviews. 1 of 1 (100%) of records reviewed revealed that the hospice did not ensure that Plans of Care for wound care patients were individualized to meet the needs of the patients for updated assessments. During an interview on 9/27/2022, the Administrator, in response to the question, "Why is there no evidence in the documentation ensuring wound care at the IDG meetings? “The Administrator stated” a corrective process” would be initiated. Clinical Record 1 The IDT/IDG, (Interdisciplinary Team Meeting), dated 8/31/2022, under the section "Current Problem List" there was no documented evidence of skin care. In the RN initial admission on 8/30/2022, the RN documented an assessment listing "Left Heel, size 6.8 cm, Pressure Ulcer (eschar). Cover ulcer on left heel with Mepalix." The IDG failed to identify treatments and interventions to address the lesion on the left heel.

It is required that consistent with current professional standards of practice, icensed professionals actively participate in the coordination of all aspects of patient care including: conducting ongoing interdisciplinary comprehensive assessments; developing and evaluating the plan of care; contributing to patient and family counseling and education. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 6 (83%) of records reviewed revealed that the hospice did not ensure that the professionals (LMSW and Chaplain) participated in the coordination of patient care and conducted initial assessments, and ongoing assessments, in the interdisciplinary team meetings. Record #1, 2, 3, 4, and 6. In an interview with the Administrator on 9/27/2022, it was stated, "We were not aware that the Social Worker and the Chaplain were to be part of the ongoing interdisciplinary comprehensive assessments."

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including: “Core” services include nursing services, medical social work, and counseling. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 6 (83%) of records reviewed revealed that the core services (LMSW and Chaplain) were not provided or offered. Record #1, 2, 3, 4, and 6. In an interview with the Administrator on 9/27/2022, it was stated, "We were not aware that the Social Worker and the Chaplain had to be offered.

It is required that medical social services are provided: Based on a psychosocial assessment; according to the patient’s and family’s needs and acceptance of these services; per the plan of care, and under the direction of a physician. The psychosocial assessment addresses: patient’s and the family’s adjustment to the terminal illness; social and emotional factors related to the terminal illness; presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, family support systems to facilitate coping with end-of-life issues, and. psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 6 (83%) of records reviewed revealed that the patients/caregivers were not assessed for Psychosocial Services. There was no documented evidence of a Psychosocial Assessment offered and/or refused. Record #1, 2, 3, 4, and 6. In an interview with the Administrator on 9/27/2022, it was stated, " We only thought that the nursing and physician services were needed for care.”.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 6 (83%) of records reviewed, revealed that the patient/caregiver were not offered spiritual services or reasonable efforts made to provide counseling services. Record #1, 2, 3, 4, and 6. In an interview on 9/27/2022, with the Administrator, it was stated that they had not been aware that patients were to be offered spiritual counseling.

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 2 (50%) applicable records of patients who received hospice aide services revealed the hospice did not ensure that the hospice aide care plans included clear and specific instructions related to the type of bath. Clinical Record # 2 record was reviewed and identified the election of benefit was dated on 09/13/2022 and resided in an assisted living facility. The record documented the patient’s age-related debility and altered mental status, which made the patient unable to make the required decision safely. The Aide Care Plan, dated 9/13/2022, assigned the aide to give a Partial Bath/Shower and Complete Shower. In an interview with the Administrator, on 9/27/2022, he stated that they will provide a plan of correction to ensure compliance.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 2 (50%) of records reviewed revealed that that hospice did not ensure the hospice aide services provided were consistent with the plan of care visit frequency. Clinical Record 1 For the Election of Benefit, beginning, 08/30/2022, an order was written for aide visits 3XW on 8/30/2022. The week of 8/30/2022 there were no aide visits completed. There was no documentation explaining the missed visit. Interview with the Administrator on 9/27/2022 stated that the aide had not reported the missed visits.

It is required the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation, provision of care and services and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. THIS IS A CMS CONDITION LEVEL CITATION. This Condition was not met as evidenced by clinical record review, personnel record review and interview, which revealed the failure of the hospice governance to appoint the Administrator [HSLG.3.I/L651]; failure to provide an orientation on hospice to staff [HSRM.15.I/L661]; responsibilities [HSLG.2.I/L651]; failure to provide qualified and licensed professionals [HSRM.3.I/L784]; failure to provide qualified MSW that meets education and experience requirements [HSRM.7.D/L787]; failure to provide core services [HCDT.2.I/L588]; failure to provide MSS services by a qualified social worker [HCDT.9.I/L594]; and failure to spiritual assessment and counseling to meet the patients' needs [HCDT/11.I/L598]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to provide quality care for the Condition of Participation CFR 418.100, Organization and Administration of Services. The collective deficient practice illustrated a systemic failure of not having processes to ensure quality patient care.

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 standard was not met as evidenced by interviews. The agency did not ensure that adequate resources were available to provide the services needed. During an interview the Administrator stated the agency transferred ownership on April 1, 2022. The current hospice staff included a social worker, chaplain/bereavement counselor, registered nurse, hospice aide, Director of Nursing/Administrator, and PRN RNs and LVNs. The agency had one Medical Director and did not have an alternate at the time of the survey. There was no documented evidence of Social Worker or Chaplain visits, phone calls or participation in IDG/IDT meetings since 4/1/0222. The current patient census at the time of this site visit was 24 patients. The Administrator confirmed these findings. Per the Administrator on April 1st, 2022, the agency transfered ownership. The current hospice staff includes a social worker, chaplain/bereavement counselor, registered nurse, hospice aide, Director of Nrsing/Administer, and PRN RNs and LVNs. The agency has one Medical Director and does not have an alternate at this time of the survey. The agency has no documented evidence of a Social Worker or Chaplain visits, phone calls or attending any IDG/IDT meetings since 4/1/0222. The current census during this site visit was 24 patients. The Administartor confirmed these findings.

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; provision of care and services; fiscal operations; and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by a review of document reviews and interviews. The hospice did not ensure that a governing body assumed the designated responsibilities as required. There were no documented Governing Board minutes since April 1, 2022, when the new ownership acquired the agency. There was no performance improvement documentation dated for the 2nd Quarter Report (April 1st through June 30th). There was no documentation of overall management and operations; provision of care and services; fiscal operations; and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually, had been addressed. During an interview, the Administrator stated that there is no documented evidence of a Governing Board being in place. There were no documented Governing Board minutes since April 1, 2022, when the new ownership acquired the agency. Per the Administrator there is no documented evidence of a Governing Board being in place. There was no Performance Improvement documentation dated for the 2nd Quarter Report (April 1st through June 30th). There was no documentation of overall management and operations; provision of care and services; fiscal operations; and ongoing Performance Improvement and Patient Safety Program that is defined, implemented, maintained, and evaluated annually, had been addressed.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following: As appropriate to the employee’s specific job duties: education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by a review of interviews and personnel records. In 5 of 5 (100%) of records reviewed revealed that the hospice did not ensure that hospice staff completed an orientation to hospice that included the required content areas. There was no documentation that the employees received specific orientation about Hospice Philosophy in the following records: #1 RN hired 8/8/2022. Staff #2 DON hired 8/29/2022. Staff #3 Chaplain hired 9/30/2019. Staff #4 LVN, hired 6/20/2022, Staff #5 Administrator hired 4/1/2022 and Staff # 6 LMSW hired 1/11/2021. In an interview on 9/27/2022 the Administrator (Staff # 5) "the initial orientation documentation should be in the employee file.”

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 6 (33%) of records reviewed revealed that the hospice did not ensure that the clinician's documentation was authenticated with credentials. Clinical Record 3 The RN visit documentation did not contain credentials after the electronic signature on the forms for dates 8/16/2022 and 8/29/2022. Clinical Record 4 The RN visit documnetation did not contain credentials after the electronic signature on the forms for dates 8/13/2022 and 8/14/2022. During an interview on 9/27/2022, the Administrator, confirmed that the credentials were missing after the signatures, and that he would be in touch with the electronic medical record company to find out how to enter in the credentials.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by a review of document reviews and interviews. The hospice did not ensure that when controlled medications were firsts ordered that written educataion on disposal of controlled medications was provided. There was no documentation supporting the patient/family received a copy of the Policy and Procedure for the Safe Management and Disposal of Controlled Medications in the Admission Packet/Patient Handbook. Per the Administrator, a copy of the Policy was included in the Admission Packet. Upon a second review of an Admission Packet there was not a copy of the Policy and Procedure for the Safe Management and Disposal of Controlled Medications, it only included a brief handout. During an interview with the Administrator on 9/27/2022, it was stated, "We will add the policy." There was no documentation supporting the patient/family received a copy of the Policy and Procedure for the Safe Management and Disposal of Controlled Medications in the Admission Packet/Patient Handbook. Per the Administrator, a copy of the Policy was included in the Admission Packet. Upon a second review of an Admission Packet there was not a copy of the Policy and Procedure for the Safe Management and Disposal of Controlled Medications, but a brief Handout. In an interview with the Administrator on 9/27/2022, it was stated, "We will add the policy."

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, [and] keep their qualifications current at all times. This standard was not met as evidenced by a review of interviews and personnel records. 1 of 4 (25%) records reviewed revealed that the hospice did not ensure that all professionals maintained current licensure to meet their respective qualifications. The LMSW (Staff # 6) personnel record was reviewed and identified the date of hire on 1/11/2022. There was no documented evidence that the LMSW file contained validation of a current license. During an interview on 9/27/2022, the Administrator stated "I do understand why the information is not in the files.”.

It is required that a social worker has: A Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; OR a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education; OR a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above; [and] at least one (1) year of social work experience in a health care setting. This standard was not met as evidenced by a review of interviews and personnel records. In 1 of 1 (100%) of record reviewed revealed the hospice did not ensure the MSW met the specific requirements related to education and experience. Staff # 6 (LMSW) was reviewed and identified a date of hire on 1/11/2022. There was no documented evidence that the Social Worker educational accreditation and experience was contained in the personnel files. In an interview with the Administrator on 9/27/2022, it was stated, "I do not know why the file is not in the records.".