Every finding on record at Seasons Hospice, Inc

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 drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile and plan of care for the palliation and management of the terminal illness. Clinical Record 2: The date of election was 11/20/2023. The Medication Profile printed on 11/11/2024 revealed Melatonin 10mg orally at bedtime, Mirtazapine 7.5mg orally at bedtime, and Tylenol 325mg 2 tablets orally every 4 hours as needed for pain. During the Home Visit (Clinical Record 2) on 11/12/2024 with the Hospice Aide (Personnel Record 11), the facility medication record lacked the Melatonin, Mirtazapine, and as needed Tylenol. The facility LPN reported that the Melatonin was discontinued on 08/27/2024, the Mirtazapine was discontinued on 09/18/2024, and the Tylenol 325mg 2 tablets every 4 hours was not found within the facility orders. Clinical Record 3: The date of election was 08/02/2024. The Medication Profile printed on 11/11/2024 revealed Albuterol Sulfate 2.5mg/3ml (0.083%) one Nebu Soln inhalation every 6 hours as needed for SOB or wheezing and Chlorhexidine Gluconate 0.12% 5ml oropharyngeal twice a day. During the Home Visit (Clinical Record 3) on 11/12/2024 with the Medical Social Worker (Personnel Record 8), the facility medication record lacked the Albuterol Sulfate and Chlorhexidine Gluconate. The facility RN reported that the Chlorhexidine Gluconate was discontinued on 07/28/2024, and the Albuterol Sulfate was not found within the facility orders. During a joint record review and interview on 11/12/2024, the Clinical Director confirmed that there was no documented evidence that medication reconciliation was completed, and medications updated to the medication profile and plan of care.

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, 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, 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 standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that medical social services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services. Clinical Record 16: The patient's date of election was 02/14/2023. The Plan of Care Order dated 02/14/2023 for the benefit period 02/14/2023-05/14/2023 and 05/03/2023 for the benefit period 05/15/2023-08/12/2023 documented "Medical Social Worker 1/mo for 3/mo with 3 PRN for psychosocial needs." The IDG Meeting note dated 05/31/2023 documented "Medical Social Worker/eff 5/19 0x month and 3 PRN psychosocial support." There was no documented evidence that social work visits were made 1 x monthly between 03/01/2023 through 05/19/2023. Clinical Record 18: The patient's date of election was 02/21/2023. The Plan of Care Order dated 02/21/2023 for the benefit period 02/21/2023-05/21/2023 documented "Medical Social Worker 1/mo for 3/mo with 3 PRN for change in condition/request." The Missed Visit Form (MSW Visit) dated 03/22/2023 documented, "Pt is in the shower at the time of visit." The Missed Visit Form (MSW Visit) dated 05/10/2023 documented, "Pt is in the salon getting her hair done at attempted visit, sw will try again." There was no additional evidence that any other attempts were made for the visits. There was no documented evidence of physician orders cancelling the social worker visits for March or May 2023. There was no documented evidence that social work visits were made 1 x monthly for March or May 2023. During a joint record review and an interview on 11/14/2024, the Executive Director confirmed that there was no documented evidence that social work services were provided during the times identified. During a joint record review and an interview on 11/14/2024, the Clinical Director confirmed that there was no documented evidence that social work services were provided during the times identified.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical record review revealed the agency did not ensure physician orders for volunteer visits. Clinical Record 2: The patient's date of election was 11/20/2023. Volunteer visit notes dated 02/05/2024 and 02/12/2024 were present in the record. The record lacked evidence of a physician's orders for the volunteer visit. During a joint record review and interview on 11/13/2024, the Clinical Director confirmed that the records lacked evidence of physician's orders for the volunteer visits.

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 2 (50%) clinical records for patients transferred to a Medicare/Medicaid certified facility reviewed revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. Clinical Record 15: The patient's care was transferred to another Hospice provider on 10/10/2024. The record lacked evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 11/13/2024, the Clinical Director confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid certified facility.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 16: The patient’s election of benefits was 02/14/2023 and discharged due to revocation on 07/15/2024. The discharge summary dated 07/15/2024 lacked documentation that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 11/13/2024, the Clinical Director confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by interview and observation. In 2 of 4 (50%) clinical records of patients residing in a Skilled Nursing Facility (SNF) reviewed during a home visit revealed the organization did not ensure the Interdisciplinary Group (IDG) provided the SNF with the physician certification and recertification of the terminal illness. Home Visit 1: The patient's date of election was 11/20/2024. During the Home Visit (Clinical Record 2) on 11/12/2024 with the Hospice Aide (Personnel Record 11), the patient’s hospice binder at the SNF was reviewed. There was no documented evidence of the physician certification and recertification of the terminal illness in the binder. Home Visit 2: The patient's date of election was 08/02/2024. During the Home Visit (Clinical Record 3) on 11/12/2024 with the Medical Social Worker (Personnel Record 8), the patient’s hospice binder at the SNF was reviewed. There was no documented evidence of the physician certification and recertification of the terminal illness in the agency binder. During a joint record review and an interview on 11/12/2024, the Executive Director confirmed there was no documented evidence of the physician certification and recertification of the terminal illness in the patient’s hospice binder at the SNF.

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; [and] the assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by organizational policy, record review and interview with the CEO/Administrator. In 3 of 3 (100%) of patients who had been on Oxygen therapy, the agency failed to ensure that the current practice of prescription and administration of oxygen therapy was documented. The policy "Medication Profile" (Policy No.2-004), (Revised 2019) read in part"...The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications." Record #54234: For the 3rd certification and start of care being from 12/01/2021 through discharge on 12/09/2021, 72-year-old female admitted to hospice with diagnosis of COPD, HTN, depression, A-flutter, HLD, acute respiratory failure, seizures, PE and morbid obesity. The RN, during the initial assessment, dated 12/01/2021, documented O2 in place at 3.5L via NC. The Oxygen was not recorded on the Medication Profile. Record #32956: For the Start of Care (SOC) from 12/28/2021 through 03/27/2022, 90-year-old female patient admitted to hospice with diagnosis of Congestive Heart Failure, and Atrial Fibrillation. he RN, during the initial assessment, dated 12/28/2021, documented O2 in place at 2.0 L via NC. The Oxygen was not listed on the Medication Profile. Record #19532: For the Start of Care (SOC) from 11/24/2021 through 02/21/2022, 75-year-old male admitted to hospice with Esophageal cancer. The RN initial assessment dated 11/24/2021 documented O2 dependent at 4 L via nasal cannula, as well as observation of O2 device in use during a home visit on 1/5/2022. the Oxygen was not listed on the Medication Profile. In an interview with the CEO/Administrator, Staff ID: 66709, on 1/05/2022 and 1/06/20221, who reviewed the records, agreed the oxygen had not been updated on the medication profile.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group included in the plan of care; permitted to be performed under state law and regulation and is consistent with the hospice aide training. This standard was not met as evidenced by organizational policy, finical record review and interview with the CEO/Administrator, which revealed 5 of 8 (63%) records of patients receiving Hospice Aide services revealed documented evidence that the Hospice Aide was not compliant with following the assigned Hospice Aide Care Plan for the specific patient being reviewed. The policy, "Hospice Aide Services" (Policy No. 9-020), (Revised October 2019) read in part"...Hospice aides will document care provided in accordance with the hospice aide." Record #40191: For the eight (8th) certifications beginning 11/08/2021 through 01/06/2022, 90-year-old admitted to services for Parkinson's disease. The Aide Care Plan, dated 10/25/2021, assigned "Aide Frequency 3 X A WEEK." The week beginning 11/14/2021, only one visit was performed, that, on 11/15/2021. The week beginning 11/21/2021, only one visit was performed dated 11/21/2021. The record lacked evidence of why the visits were not completed as ordered. Record #44717: For the Start of Care (SOC) beginning 12/02/2021 through 03/01/2022, 75-year-old male patient admitted to services for Senile Degeneration of the Brain and Parkinson's Disease. The Aide Care Plan, dated 12/02/2021, assigned “Aide Frequency 2 X A WEEK." The first week only one aide visit was performed, this on 12/02/2021. The record lacked evidence of why the visits were not completed as ordered. Record #75686: For the Start of Care (SOC) beginning 11/18/2021 through 02/15/2022, 65-year-old female patient admitted for Parkinson's Disease and COPD. The Aide Care Plan, dated 11/18/2021, assigned “Aide Frequency 2 X A WEEK." The first week only one aide was performed, that on 11/19/2021. The record lacked evidence of why the visits were not completed as ordered. Record #60420: For the sixth certification beginning 12/02/2021 through 01/30/2022, 85-year-old female patient admitted for Senile degeneration of brain and COPD. The Aide Care Plan, dated 11/23/2021, assigned "Aide Frequency 2 X A WEEK." The week beginning 12/26/2021, there was only one visit performed, that on 12/28/2021. The record lacked evidence of why the visits were not completed as ordered. Record #32956: For the Start of Care (SOC) beginning 12/28/2021 through 03/27/2022, 90-year-old female patient admitted with diagnosis of Congestive Heart Failure and Atrial Fibrillation. The Aide Care Plan, dated 12/28/2021, assigned "Aide Frequency 2 X A WEEK." The first week there was recorded only one visit performed on 12/29/2021. The record lacked evidence of why the visits were not completed as ordered. In an interview with the CEO/Administrator, Staff ID: 66709, on 1/05/2022 and 1/06/20221, they having reviewed the records, agreed the visits were not completed as ordered and the record lacked evidence of why the visits were not completed.

It is required that the hospice discharge summary is provided to a facility receiving a hospice patient for care-or to the patient's community attending physician upon hospice discharge. This is to include at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; patient’s current plan of care, 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 the review of organizational policy, the clinical record review, and an interview with the CEO/Administrator. This revealed that the agency had failed in 1 of 2 (50%) records reviewed that the agency neglected to ensure that a completed discharge summary had been sent to the receiving facility and/or the community physician. The policy "Discharge Summary" (Policy No. 1-026 (Revised 9/2020) read in part"...Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include: The reason for discharge, including the name of the organization to which the patient is being transferred, status of problems identified at admission and during the provision of care, and the resolution of identified problems". In addition, "date the physician notified, resolution of problems, continuing symptom management needs, including status of patient, overall status of the patient, summary of the care provided and current plan of care as well as latest physician orders." Record #54234: For the Certification beginning on 12/01/2021, diagnosis included Chronic obstructive pulmonary disease, Hypertension and Oxygen dependent at 3.5 L per nasal cannula. On 12/09/2021, the Patient reports increased SOB, dyspnea noted at rest. The patient/caregiver had opted to revoke services due shortness of breath. The discharge summary 12/09/2021, "Patient reports she wants to go to hospital, refused for nurse to administer medications to help her be more comfortable. Notified hospice MD., orders received to discharge patient to the hospital." The Discharge Summary provided to the receiving facility, failed to detail treatments, pain management, latest plan of care, and other pertinent documentation to assist the post-discharge receiving facility in terms of supplying that organization the needed information to ensure continuity of care. In an interview with the CEO/Administrator, Staff ID: 66709, on 1/05/2022 and 1/06/20221, who reviewed the records, agreed the discharge summary had been completed per policy.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review of contracts and an interview with the Administrator. This revealed that the LTCF, Respite/Inpatient, Pharmacy, and Therapy (PT/OT/ST) contracts failed to include the clause, in writing, between the contractor/contractee for the provision that requires criminal background checks. An interview was conducted on 1/05/2022 and 1/06/2022 with the CEO/Administrator, Staff ID: 66709, who stated that they would provide an addendum to ensure compliance.