Every finding on record at Select Hospice Care LLC

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below, and the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below, and the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below, and the hospice maintains documentation that each hospice aide has met the requirements. Documentation of training includes a description of the training and competency evaluation program, the qualifications of the instructor, a statement that distinguishes skills taught in a laboratory using a real person (not a mannequin), indicators of which skills the aide was judged to be competent in, and how additional skills, if any, are taught and tested if the hospice’s admission policies and case-mix of hospice patients requires aides to perform more complex procedures. Option 1: Hospice Aide Training and Competency Evaluation: a qualified hospice aide has successfully completed: 1) A training program and competency evaluation that includes classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while performing tasks on an individual under the direct supervision of a registered nurse or licensed practical nurse who is under the supervision of a registered nurse: a) classroom and supervised practical training that total at least 75 hours b) a minimum of 16 hours of classroom training that precedes a minimum of 16 hours of supervised practical training as part of the 75 hours, and a training program that addresses each of the following subject areas communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff, observation, reporting, and documentation of patient status and the care or service provided, reading and recording temperature, pulse, and respiration, basic infection control procedures, basic elements of body function and changes in body function that must be reported to an aide’s supervisor, maintenance of a clean, healthy, and safe environment, recognizing emergencies and the knowledge of emergency procedures and their application, the physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property, appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed), nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and fluid intake, and any other task that the hospice may choose to have an aide perform not addressed in item 2.i (a-f) above, the basic checklist; and the competency evaluation addresses each of the following subject areas from item 2, above; they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff, reading and recording temperature, pulse, and respiration, appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist, bed bath, sponge, tub, and shower bath, hair shampoo (sink, tub, and bed), nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning. The remaining subject areas in item 2 above may be evaluated through written examination, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation, and the competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate, a hospice aide is not considered competent in any task for which he or she is evaluated as “unsatisfactory.” A hospice aide may not perform that task without direct supervision by a registered nurse until after he or she has received training in the task for which he or she was evaluated as “unsatisfactory” and has successfully completed a subsequent evaluation. A hospice aide is not considered to have successfully completed a competency evaluation if the aide has an “unsatisfactory” rating in more than one (1) of the required areas, and the hospice maintains documentation that demonstrates the requirements of competency evaluation are met (items 3-5 above). Option 2. Hospice Aide Training and Competency Evaluation: a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff, reading and recording temperature, pulse, and respiration, appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath, hair shampoo (sink, tub, and bed), nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: observation, reporting, and documentation of patient status and the care or service provided, basic infection control procedures, basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor, maintenance of a clean, safe, and healthy environment, recognizing emergencies and the knowledge of emergency procedures and their application, the physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property, adequate nutrition and fluid intake, any remaining task(s) that the hospice chooses to have an aide perform; and the competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate; and a hospice aide is not considered competent in any task for which he or she is evaluated as “unsatisfactory.”. A hospice aide may not perform that task without direct supervision by a registered nurse until after he/she has received training in the task for which he/she was evaluated as “unsatisfactory” and has successfully completed a subsequent evaluation. A hospice aide is not considered to have successfully completed a competency evaluation if the aide has an “unsatisfactory” rating in more than one (1) of the required areas, and the hospice maintains documentation that demonstrates the requirements of competency evaluation are met. Option 3: Hospice Aide Training and Competency Evaluation: a qualified hospice aide has completed a nurse aide training and competency evaluation program approved by the state as meeting the requirements of nurse aide training and competency evaluation per CMS CFR 483.151-154 (state approval of aide training and competency program per regulation, and is currently listed in good standing on the state nurse aide registry .Option 4 : Hospice Aide Training and Competency Evaluation: a qualified hospice aide has completed a state licensure program. This standard was not met as evidenced by interview and personnel record review. In 1 of 2 (50%) hospice aide personnel records reviewed, the agency did not ensure that the hospice aide successfully completed a competency evaluation program which included observation of a hospice aide's performance with a patient or pseudo-patient satisfactorily prior to performing patient care. PERSONNEL RECORD 1: This hospice aide was hired on 07/19/2025. The personnel record review revealed that the hospice aide initial competency was performed on 07/23/2025. The following tasks were documented as "discussed": sponge bath, tub bath, shower, shampoo in sink, shampoo in tub, and shampoo in bed. This discussion was signed and dated by the Registered Nurse on 07/23/2025. In an interview conducted with the Director of Nursing on 08/14/2025, it was stated that a home visit was conducted on 07/23/2025. The hospice aide was observed performing a bed bath only. The following tasks were not observed but discussed with the hospice aide: sponge bath, tub bath, shower, shampoo in sink, shampoo in tub, and shampoo in bed. The hospice aide was then permitted to perform all hospice aide tasks independently. The Administrator stated that the hospice aide competency would be completed before the hospice aide performed any of the tasks that had not been observed by the Registered Nurse.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 3 (67%) clinical records reviewed revealed the patient's individual written plan of care (POC) lacked interventions based on problems identified in the initial and updated comprehensive assessments. Document 3: The Policy #9.12.1, "IDG Care Planning Process (Dated: 2/2022)," stated in part, "Policy: In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with patient's needs and goals as a priority. The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs." Clinical Record 1: The patient elected the hospice benefit on 5/20/23. The initial nursing assessment dated 5/20/23 stated the patient had a coccyx wound and a foley catheter. The interdisciplinary group (IDG) plan of care (POC) dated 5/20/23 lacked the intervention(s) for the specific wound care treatment for coccyx wound and the intervention(s) for the foley catheter. Clinical Record 3: The patient elected the hospice benefit on 6/23/23. The initial nursing assessment dated 6/23/23 stated that the patient had one (1) wound, a stage 2 pressure sore on coccyx. The IDG POC dated 6/23/23 lacked the intervention(s) for the specific wound care treatment for the coccyx wound. Upon interview on 8/11/23, the Administrator/Hospice Medical Director reviewed and agreed the IDG POC for the patient's above lacked specific interventions for the coccyx wounds and urinary catheter.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 2 (50%) personnel records reviewed of hospice aides hired since 12/2022 revealed the hospice did not ensure that the hospice aide successfully completed a competency evaluation program. Document 2: The, "Initial Competency - Hospice Aide 4A.14.1," lacked, "Nail and skin care" under the "Skills" section. Personnel Record 1: The Hospice Aide was hired on 7/14/23. The initial competency dated 7/14/23 lacked skill validation for, "iv. Nail and Skin Care". The competency was signed and dated by the Registered Nurse and the Hospice Aide on 7/14/23. Upon interview on 8/11/23, the Administrator/Hospice Medical Director reviewed and agreed the, "Initial Competency - Hospice Aide 4A.14.1," was not updated to include "Nail and skin care" under the "Skills" section. The record lacked documented evidence that a Registered Nurse observed the "Nail and skin care" to competency the Hospice Aide.

It is required that a hospice may contract for medical director services with either a self-employed physician, or a physician employed by a professional entity or physician group. The contract specifies the physician who assumes the medical director responsibilities and obligations. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) contract reviewed for the Hospice Medical Director revealed the agency did not ensure the contract specified the physician who would assume the medical director responsibilities and obligations when the medical director was not available. Document 1: The "Hospice Medical Director job description (Dated: 2014)," stated in part, "Essential Functions: 5. When the Medical Director is not available, a physician designated by Hospice assumes the same responsibilities and obligations as the Medical Director." Contract 1: The Hospice Medical Director contract dated 12/14/22, lacked a physician designated by the Hospice as to who assumed the same responsibilities as the Medical Director when the Medical Director was not available. Upon interview on 8/11/23, the Hospice Medical Director/Administrator reviewed and agreed the agency did not ensure documentation of a specific physician who would assume the medical director responsibilities and obligations when not available. It was stated by the Hospital Medical Director, "We do not have an alternate medical director right now. The position is posted."

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address arrangements with facilities and other providers to receive patients to maintain the continuity of care to patients. CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure to develop arrangements with other facilities and providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to patients. Review of the Emergency Preparedness binder and contracts revealed no arrangements were in place with another hospice to receive patients in the event of limited or cessation of operations. During an interview on 12/9/2022, the Administrator/Medical Director stated the Hospice did not have an agreement with a hospice to receive patients in the event of an emergency or disaster. The Administrator/Medical Director stated, “we are still working on this but do not have an agreement yet." The hospice did not ensure arrangements with other facilities and providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services were developed. Review of the Emergency Preparedness binder and contracts revealed no arrangements were in place with another hospice to receive patients in the event of limited or cessation of operations. During an interview on 12/9/2022, the Administrator/Medical Director stated the Hospice did not have an agreement with a hospice to receive patients in the event of an emergency or disaster. The Administrator/Medical Director stated, “we are still working on this but do not have an agreement yet."

It is required that the hospice conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise or a mock disaster drill or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure the emergency plan was activated during the COVID-19 public health emergency (PHE) and did not ensure exercises were conducted to test the emergency plan at least annually. Review of the emergency preparedness binder revealed missing exercises or drills for 2020 and 2021. There was no evidence the emergency plan was activated during the COVID-19 public health emergency (PHE). A mock disaster drill was completed 9/21/2022. During an interview on 12/9/2022, the Administrator/Medical Director stated, "we are working on the COVID-19 emergency plan and plan to implement it by next week." The hospice did not ensure the emergency plan was activated during the COVID-19 public health emergency (PHE) and did not ensure exercises were conducted to test the emergency plan at least annually. Review of the emergency preparedness binder revealed missing exercises or drills for 2020 and 2021. There was no evidence the emergency plan was activated during the COVID-19 public health emergency (PHE). A mock disaster drill was completed 9/21/2022 and the previous exercise was completed 5/17/2019. During an interview on 12/9/2022, the Administrator/Medical Director stated, "we are working on the COVID-19 emergency plan and plan to implement it by next week."

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including the following: intervention to manage pain and symptoms; measurable outcomes anticipated from implementing and coordinating the plan of care. CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure the plan of care reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Clinical Record #1: was reviewed and identified the patient accepted hospice care on 11/7/2022 with a terminal diagnosis of Parkinson’s disease. The initial comprehensive assessment completed on 11/7/2022 by the registered nurse (RN) documented, “2+ bilateral edema....patient is very weak and unsteady....patient tries to get up on his own at times and is a fall risk...He has a hx of 2 recent falls without injury other than bruising." The RN assessment completed on 11/21/2022 documented, “2+ RLL edema... 1+LLE getting weaker and more unsteady.” The plan of care dated 11/7/2022 through 12/8/2022 did not include goals or interventions for the edema or safety related to falls. During an interview and a joint review of the record on 12/8/2022, the Administrator confirmed that there were no care plan interventions and goals for the edema and safety related to falls. Clinical Record #1: was reviewed and identified the patient accepted hospice care on 11/7/2022 with a terminal diagnosis of Parkinson’s disease. The initial registered nurse (RN) comprehensive assessment on 11/7/2022 revealed, “2+ bilateral edema,” "patient is very weak and unsteady,” “patient tries to get up on his own at times and is a fall risk. He has a hx of 2 recent falls without injury other than bruising." The RN comprehensive assessment on 11/21/2022 revealed, “2+ RLL edema, 1+LLE getting weaker and more unsteady.” The plan of care was reviewed for 11/7/2022-12/8/2022. The plan of care did not include goals or interventions for the edema or safety related to falls. During interview and a joint review of the record on 12/8/2022, the Administrator confirmed that there were no care plan interventions and goals for the edema and safety related to falls.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of personnel records and interviews. 2 of 2 (100%) personnel records reviewed of hospice aides revealed the hospice did not ensure that the hospice aide successfully completed a competency evaluation program. Staff 1: Review of the personnel record for the hospice aide hired on 3/24/2022, revealed the "initial Competency Hospice Aide" form dated 3/29/2022 was signed and dated by the hospice aide, the skills "normal range of motion," "fluid intake," and "adequate nutrition" were marked NA. The skills "nail and skill care" were not on the checklist and did not include any documented evidence the aide was competent. There was no evidence that the aide had successfully completed a competency evaluation program as of 12/8/2022. Staff 7: Review of the personnel record for the hospice aide hired on 6/20/2022, revealed the "Initial Competency Hospice Aide" form dated 6/20/2022 was signed and dated by the hospice aide, skills were marked "Yes...competent," the "Completion Date" was left blank, and the section "Observed in home with patient Yes or No" was left blank. The skills "nail and skill care" were not on the checklist and did not include documented evidence the aide was competent. There was no evidence that the aide had successfully completed a competency evaluation program as of 12/8/2022. During an interview on 12/8/2022, the Administrator/Medical Director agreed, there was no documented evidence that a Registered Nurse observed the required skills on the competency. Staff 1: Review of the personnel record for the hospice aide hired on 3/24/2022, revealed the "initial Competency Hospice Aide" form dated 3/29/2022 was signed and dated by the hospice aide, the skills "normal range of motion," "fluid intake," and "adequate nutrition" were marked NA. The skills "nail and skill care" were not on the checklist and did not include any documented evidence the aide was competent. Staff 7: Review of the personnel record for the hospice aide hired on 6/20/2022, revealed the "Initial Competency Hospice Aide" form dated 6/20/2022 was signed and dated by the hospice aide, skills were marked "Yes...competent," the "Completion Date" was left blank, and the section "Observed in home with patient Yes or No" was left blank. The skills "nail and skill care" were not on the checklist and did not include any documented evidence the aide was competent. During an interview on 12/8/2022, the Administrator/Medical Director agreed, there was no documented evidence a Registered Nurse observed the required skills on the competency.

It is required that a hospice may contract for medical director services with either a self-employed physician; or a physician employed by a professional entity or physician group. The contract specifies the physician who assumes the medical director responsibilities and obligations. CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by document reviews, interviews, and personnel records review. 2 of 2 (100%) physician records revealed the hospice did not ensure contracts were in place for the contracted Medical Director and Alternate Medical Director. Staff 8: Review of the personnel record for the Alternate Medical Director revealed a missing contract. The agency was unable to provide the contract for the Alternate Medical Director. During an interview on 12/8/2022, the Administrator/Medical Director stated the Alternate Medical Director stated, “when I contacted him during the last survey, he said he no longer wanted to be the alternate medical director, we are searching for an alternate medical director but haven’t found one yet.” Staff 4: Review of the personnel record for the Medical Director revealed the contract did not specify the physician who assumes the medical director responsibilities and obligations. The Administrator/Medical Director stated, “this contract needs to be updated.” Staff 8: Review of the personnel record for the Alternate Medical Director revealed a missing contract. The agency was unable to provide the contract for the Alternate Medical Director. During an interview on 12/8/2022, the Administrator/Medical Director stated the Alternate Medical Director is no longer working for the hospice agency. On 12/8/2022, the Administrator/Medical Director stated, “when I contacted him during the last survey, he said he no longer wanted to be the alternate medical director, we are searching for an alternate medical director but haven’t found one yet.” Staff 4: Review of the personnel record for the Medical Director revealed the contract did not specify the physician who assumes the medical director responsibilities and obligations. The Administrator/Medical Director stated, “this contract needs to be updated.”

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address arrangements with facilities and other providers to receive patients to maintain the continuity of care to patients. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure arrangements with other facilities and providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services were developed. Review of the Emergency Preparedness binder and contracts revealed no arrangements were in place with another hospice to receive patients in the event of limited or cessation of operations. During an interview on 10/27/22, the Administrator/Medical Director stated the Hospice did not have an agreement with a hospice to receive patients in the event of an emergency or disaster. Review of the Emergency Preparedness binder, contracts and interviews revealed a missing arrangement with a hospice to receive patients in the event of limited or cessation of operations to maintain the continuity of services to hospice patients, as required in 418.113(b)(5), E-25. During interview 10/27/22, the Administrator/Medical Director stated the Hospice did not have an agreement with a hospice to receive patients in the event of an emergency or disaster.

It is required that the hospice conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise or a mock disaster drill or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure that exercises were conducted to test the emergency plan at least annually. Review of the emergency preparedness binder revealed missing exercises or drills for 2020 and 2021. There was no evidence of the activation of the COVID-19 emergency plan during 2020, 2021, and 2022. A mock disaster drill was completed 9/21/22 and the previous exercise was completed 5/17/19. During an interview on 10/27/22, the Licensed Vocational Nurse presenting the emergency plan drills and exercises stated "5/17/22 and 9/21/22 are the only disaster drills that we had." Review of the emergency preparedness binder revealed missing exercises or drills for 2020 and 2021. Additionally, there was no evidence of the activation of the COVID-19 emergency plan during 2020, 2021 and 2022. A mock disaster drill was completed 9/21/22 and the previous exercise was completed 5/17/19. During interview 10/27/22, the LPN presenting the emergency plan drills and exercises stated "5/17/22 and 9/21/22 are the only disaster drills that we had".

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. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 3 of 11 (27%) clinical records reviewed revealed the agency did not ensure the medication profile included all prescription medications. The agency policy #11.10.1 "Medication Profile" (revised June 2019) stated in part, "Hospice provides a mechanism for documentation of patient prescriptions...all prescribed medications will be documented on the medication profile". Clinical Record #4: Review of the record revealed the physician order dated 9/23/22 for "Oxygen 2-4 liters continuous," was not included on the medication profile per the agency's policy. During an interview on 10/26/22, the Administrator reviewed and confirmed the medication was not included on the medication profile. Clinical Record #8: Review of the record revealed the physician order dated 9/3/22 for "Oxygen 2-4 liters continuous," was not included on the medication profile per the agency's policy. During an interview on 10/26/22, the Administrator reviewed and confirmed the medication was not included on the medication profile. Clinical Record #11: Review of the record revealed the physician order dated 5/28/22 for "Oxygen 2-4 liters continuous," was not included on the medication profile per the agency's policy. During an interview on 10/26/22, the Administrator reviewed and confirmed the medication was not included on the medication profile.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including the following: intervention to manage pain and symptoms; measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) clinical records reviewed revealed the agency did not ensure the plan of care reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Clinical Record #4: was reviewed and identified the patient accepted hospice care on 9/23/22. The initial comprehensive assessment completed on 9/23/22 documented the patient's self-care deficit and need for Hospice aide services. The plan of care ordered the aide visit frequency of "2xweek." The plan of care did not include goals and interventions for the patient's identified problem of self-care deficit. During an interview and a joint review of the record on 10/26/22, the Administrator confirmed that there were no goals and interventions for the identified problem of self-care deficit. Clinical Record #2: was reviewed and identified the patient accepted hospice care on 9/19/22. The initial comprehensive assessment completed on 9/19/22 documented in part, "16 French 10cc Foley catheter inserted on 9/9/22." The prn nursing visit note dated 9/19/22 documented, "18French 5cc Foley catheter inserted." The plan of care did not contain goals and interventions for the identified Foley catheter insertion and care. Additionally, the initial comprehensive assessment completed on 9/19/22 documented the patient's self-care deficit and need for Hospice aide services. The plan of care ordered the aide visit frequency of "2xweek." The plan of care did not include goals and interventions for the patient's identified problem of self-care deficit. During interview and a joint review of the record on 10/26/22, the Administrator confirmed that there were no orders or interventions/goals on the record to date for the Foley catheter and for the identified problem of self-care deficit. Clinical Record #11: was reviewed and identified the patient accepted hospice care on 12/22/21 with a terminal diagnosis of COPD. The plan of care did not include interventions or goals for the identified problem of COPD. Additionally, the initial comprehensive assessment identified the problem of pelvic pain. The patient was taking Tylenol and Tramadol to control the pain. The plan of care did not include goals and interventions for pain control and was missing orders for the Tylenol and Tramadol. During interview and a joint review of the record on 10/26/22, the Administrator confirmed that there were no orders for the Tylenol and Tramadol in the clinical record and no care plan interventions and goals on for COPD or pain.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; 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. 2 of 11 (18%) clinical records reviewed revealed the agency did not include treatment orders on the plan of care.. Clinical Record #2: was reviewed and identified the patient elected hospice care on 9/19/22. The start of care nursing note dated 9/19/22 documented, "16 French 10cc Foley catheter inserted on 9/9/22." The 9/19/22 prn nursing note documented, "18 French 5cc Foley catheter inserted." During an interview and joint review of the record on 10/26/22, the Administrator confirmed that there were no orders or interventions/goals on the record for Foley catheter. Clinical Record #1: was reviewed and identified the patient elected hospice care on 9/26/22. The plan of care did not include wound care for the patient's right shin or left arm as identified and provided in the skilled nursing visit notes dated 9/26/22 through 10/11/22. The nursing note dated 9/27/22 documented, "cleansed with normal saline, bacitracin applied and secured with kerlix." The nursing note dated 9/30/22 documented, "shin open to air, shoulder cleansed with normal saline, bacitracin applied and secured with tape." The nursing note dated 10/7/22 documented, "skin tear left arm cleansed with normal saline, bacitracin applied and secured with kerlix." The nursing note dated 10/11/22 documented, "bacitracin and nonadherent dressing applied and secured with Coban." During an interview on 10/27/22, the Administrator confirmed the plan of care and record were missing wound care orders.

It is required that the hospice must document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. This standard was not met as evidenced by a review of document reviews and interviews which revealed the hospice did not ensure to document what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Review of the quality assessment/performance improvement (QAPI) binders, reports and minutes for 2020, 2021 and 2022 revealed missing performance improvement projects (PIP's). Review of the QAPI Plan in the policy and procedure manual included format forms to be utilized for PIP's. During interview 10/27/22, the Licensed Vocational Nurse who discussed and reviewed the QAPI documents stated she could not locate the missing PIPs for 2020, 2021 and 2022. During an interview on 10/27/22, the Administrator/Medical Director stated she did not currently have a Nursing Director or Alternate Nursing Director as part of the QAPI program. Review of the quality assessment/performance improvement (QAPI) binders, reports and minutes for 2020, 2021 and 2022 revealed missing performance improvement projects (PIP's). During interview 10/27/22, the Administrator/Medical Director stated she did not currently have a Nursing Director or Alternate Nursing Director as part of the QAPI program. Review of the QAPI Plan in the policy and procedure manual included format forms to be utilized for PIP's. During interview 10/27/22, the LPN who discussed and reviewed the QAPI documents stated she could not locate the missing PIPs for 2020, 2021 and 2022.

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 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 which revealed the hospice did not ensure that the QAPI program was implemented, maintained, and evaluated annually by the hospice's governance. The hospice’s policy #7.1.1 "Governing Body” (revised June 2019), stated in part, "The Governing Body members fulfill their responsibilities including attending meetings, budget oversight and evaluating senior management…The Governing Body meets at least annually to review the operation of hospice and documents all meetings by minutes…The Governing Body is responsible for ensuring that an ongoing program for QAPI and patient safety is defined, implemented, maintained and evaluated annually…The Governing Body has appointed the Administrator and Nursing Director as responsible for the ongoing administration of the QAPI program.” The Governing Body (GB) minutes were requested for review on 10/25/22, 10/26/22 and 10/27/22. There were no GB meetings documented by minutes and no evidence the Governing Body met at least annually to review the operations of the hospice for 2020, 2021 or 2022, as per the hospice's policy. GB meeting minutes were not provided during the site visit. There was no evidence that the GB established, approved, implemented and evaluated the Quality Assurance/Performance Improvement (QAPI) Plan annually, as per the hospice's policy. During an interview on 10/27/22, the Administrator/Medical Director stated there were no Governing Body minutes to present and that she did not currently have a Nursing Director or Alternate Nursing Director for the QAPI program. The Governing Body minutes were requested 10/25/22, 10/26/22 and 10/27/22 and the Hospice did not present a minimum of annual Governing Body minutes for 2020, 2021 or 2022, as required in agency policy. There was no evidence the Governing Body established, approved, implemented and evaluated the Quality Assurance/Performance Improvement (QAPI) Plan annually, as required in agency policy. The agency "QAPI Plan" was filed in the Policy and Procedure manual. Additionally, there was no evidence the Governing Body met at least annually to review the operations of he hospice and documented all meetings by minutes, as required by agency policy. During interview 10/27/22, the Administrator/Medical Director stated there were no Governing Body minutes to present and that she did not currently have a Nursing Director or Alternate Nursing Director for the QAPI program. Policy "Quality Assurance/Performance Improvement (QAPI) Plan", Policy number 10.1.3, included in part, "Governing Body ultimately responsible for QAPI and implementation of plan", and "QAPI committee will meet on regular basis and will report to Administrator and Governing Body". Policy, "Governing Body", Policy number 7.1.1, revised June 2019, included in part, "The Governing Body members fulfill their responsibilities including attending meetings, budget oversight and evaluating senior management", "The Governing Body meets at least annually to review the operation of hospice and documents all meetings by minutes", "The Governing Body is responsible for ensuring that an ongoing program for QAPI and patient safety is defined, implemented, maintained and evaluated annually" and "The Governing Body has appointed the Administrator and nursing Director as responsible for the ongoing administration of the QAPI program".

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness. This standard was not met as evidenced by a review of document reviews and interviews. The agency did not ensure that the hospice governing body was responsible for ensuring that the program addressed efforts and set priorities for improved quality of care and patient safety and ensured all improvement actions are evaluated for effectiveness. The agency's policy #10.1.3 "Quality Assessment/Performance Improvement (QAPI) Plan" stated in part, "Governing Body ultimately responsible for QAPI and implement plan...QAPI committee will meet on a regular basis and will report to the Administrator and Governing Body...Results will be communicated by QAPI committee to staff, including contract staff." Review of the agency's QAPI binders, reports and minutes for 2020, 2021 and 2022 revealed missing QAPI committee meetings. The QAPI program documents revealed no QAPI meetings or reports for the 1st, 3rd and 4th quarters of 2020, all of 2021, and the 3rd quarter 2022. The last QAPI committee meeting and report was completed on 6/29/22. Review of the QAPI program reports and meeting minutes, and administrative documents for 2020, 2021 and 2022 revealed no evidence that the agency was tracking infections including COVID-19 infections in patients and employees, patient complaints/grievances, satisfaction surveys, and indicators related to improved palliative outcomes. There was no evidence that the QAPI committee meeting results were communicated to all staff, including contract staff. Review of the QAPI documents revealed missing improvement actions that were implemented and the evaluation of the effectiveness of the improvement actions. The Governing Body meeting minutes were requested for review on 10/25/22, 10/26/22 and 10/27/22. There were no meeting minutes provided and no evidence the Governing Body met at least annually to review the operations of the hospice. There was no evidence that the Governing Body set priorities for the improved quality of care and patient safety and ensured all improvement actions were evaluated for effectiveness. . . During interview 10/27/22, the Administrator/Medical Director stated there were no Governing Body minutes to present and that she did not currently have a Nursing Director or Alternate Nursing Director for the QAPI program. The Licensed Practical Nurse who discussed and reviewed the QAPI documents, stated there were no additional QAPI documents for 2020, 2021 and 2022 which addressed improvement actions taken and the effectiveness. Review of the quality assessment/performance improvement (QAPI) documents for 2020, 2021 and 2022 revealed the Hospice Governing Body was responsible for ensuring that the program addressed efforts and set priorities for improved quality of care and patient safety, and ensured all improvement actions are evaluated for effectiveness. There were no documented Governing Body minutes or reports on the evaluation of the effectiveness of improvement actions. Policy "Quality Assessment/Performance Improvement (QAPI) Plan", policy number 10.1.3, included in part, "Governing Body ultimately responsible for QAPI and implement plan", "QAPI committee will meet on a regular basis and will report to the Administrator and Governing Body" and "Results will be communicated by QAPI committee to staff, including contract staff". The QAPI program reports , documents and minutes for 2020, 2021 and 2022 were missing COVID-19 infection reports for positive and persons under investigation (PUI) infection tracking of patients and staff, patient complaints/grievances, Hospice satisfaction surveys, indicators related to improved palliative outcomes, no reports which Involved all hospice services, including those provided under contract (Nursing, social worker, counseling, medical director/alternate) as required in the QAPI plan. Review of the QAPI documents revealed missing improvement actions that were implemented and missing the evaluation of the effectiveness of improvement actions. During interview 10/27/22, the Administrator/Medical Director stated there were no Governing Body minutes to present and that she did not currently have a Nursing Director or Alternate Nursing Director for the QAPI program. During interview 10/27/22, the LPN who discussed and reviewed the QAPI documents stated there were no additional QAPI documents for 2020, 2021 and 2022 which addressed improvement actions taken and the effectiveness.

It is required that 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 review and interview with the Administrator. The hospice failed to ensure that nursing, medical social work, and counseling core services were provided directly by hospice employees [HCDT.2.I/L588]. The cumulative effect of this issue has resulted in the hospice’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.65: Core Services. The deficient practice illustrated process failures that had the potential to affect all patients cared for by the agency. During interview 10/26/22, the Administrator/Medical Director stated, "Yes, the nurses, social worker and spiritual counselor/bereavement counselor are under signed agreement with the Hospice with a W-9". Additionally during interview 10/26/22, the Administrator/Medical Director stated "the nurses, social worker and spiritual counselor/bereavement counselor are under agreement and not directly employed because they get paid by the visit". During interview 10/27/22, the HR Coordinator stated the nurses, social worker and spiritual counselor/bereavement counselor do not have taxes taken out of their contracted pay.

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 review of documents, personnel records, and interview. 5 of 5 (100%) personnel records reviewed of nursing, social worker and spiritual counselor/bereavement counselor revealed the hospice did not ensure to routinely provide substantially all core services directly by hospice employees. Staff # 2: Review of the personnel record revealed the Registered Nurse (RN) was hired on 8/27/22 and signed an employment agreement with the hospice with a completed 1099 and W-9. Staff #3: Review of the personnel record revealed the RN was hired on 6/30/21 and signed an employment agreement with the hospice with a completed 1099 and W-9. Staff #4: Review of the personnel record revealed the Licensed Vocational Nurse was hired on 12/20/21 and signed an employment agreement with the Hospice with a completed 1099 and W-9. Staff #5: Review of the personnel record revealed the Social Worker was hired on 11/13/17 and signed an employment agreement with the hospice with a completed 1099 and W-9. Staff #8: Review of the personnel record revealed the Spiritual Counselor/Bereavement Counselor was hired on 12/18/20 and signed an employment agreement with the hospice with a completed 1099 and W-9. During an on interview 10/26/22, the Administrator/Medical Director stated, "Yes, the nurses, social worker and spiritual counselor/bereavement counselor are contracted with the hospice with a W-9...and not directly employed because they get paid by the visit". During interview 10/27/22, the Human Resources Coordinator stated the nurses, social worker and spiritual counselor/bereavement counselor do not have taxes taken out of their contracted pay.

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 IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by review of clinical records, personnel records, and interview which revealed that the agency failed to ensure written patient care instructions for a hospice aide [HCDT.15.I/L625]; failed to ensure the hospice aides followed the established aide plan of care [HCDT.16.I/L626]; and failed to ensure the hospice aide successfully completed a competency evaluation program [HSRM.9.I/L615]. The cumulative effect of these deficiencies could place the patient in jeopardy for a safety risk or for a lack of quality care.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. This standard was not met as evidenced by interviews and personnel records review. 2 of 2 (100%) personnel records reviewed of hospice aides revealed the hospice did not ensure that the hospice aide had successfully completed a competency evaluation program. Staff 5: Review of the personnel record for the hospice aide hired on 6/20/20, revealed the "Initial Competency Hospice Aide" form dated 6/20/20 was signed and dated by the hospice aide, all required skills were marked "Yes...competent," the "Completion Date" was left blank, and the section "Observed in the home with patient" was left blank. The form did not include the signature of a registered nurse (RN). During an interview on 10/27/22, the hospice aide stated she remembers going out in the field with the Licensed Vocational Nurse (LVN) and not with an RN. Staff 6: Review of the personnel record for the hospice aide hired on 3/24/22, revealed no evidence of an aide competency. During an interview 10/27/22, the Human Resources Coordinator confirmed the missing an initial competency evaluation.

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 10 (10%) clinical records reviewed of patients who received hospice aide services revealed the hospice did not ensure the hospice aide care plan included specific written instructions for the hospice aide. Clinical Record #9: was reviewed and revealed the patient elected hospice care on 4/22/22, the patient was forgetful, alert to person only and the patient lived in a group home. The aide care plan assigned the aide the tasks "perform a partial bath/shower every visit." The aide care plan did not include additional instructions for the aide as to when to perform the "partial bath" or the "shower." Review of the aide visit notes revealed the hospice aide documented each visit "completed... partial bath/shower." There was no evidence of communication with the Registered Nurse as to which type of bath the aide should perform. During an interview on 10/27/22, the Administrator and a Licensed Practical Nurse confirmed the aide care plan assigned the aide to perform a a bath and a shower every visit with no additional instructions as to when to perform the "partial bath" or the "shower."

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. 3 of 10 (30%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure assigned visits and/or tasks were completed as ordered by the Interdisciplinary Group, included in the plan of care. Clinical Record #4: The plan of care dated 9/23/22, ordered an aide frequency of "2xweek." Review of the clinical record revealed there were no aide visits completed during the week of 9/23/22 and no missed visits documented by the aide. During an interview 10/26/22, the Administrator agreed with no visits were made the week of 9/23/22. Clinical Record #9: The aide care plan dated 4/22/22 assigned the aide to complete each during every visit. The aide visits documented as completed on 7/11/22 through 7/18/22 did not include evidence that the aide completed the following assigned tasks: make bed, change linens. During an interview on 10/26/22, the Administrator agreed all tasks assigned were not completed. Clinical Record #11: The plan of care dated 5/28/22, ordered an aide frequency of "2xweek." Review of the clinical record revealed there were no aide visits completed during the week of 5/28/22 and and no missed visits documented by the aide. During an interview 10/26/22, the Administrator agreed with no visits were made the week of 9/23/22.

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 CONDITION was not met as evidenced by clinical record review, personnel record review and interview, which revealed the hospice failed to ensure that an Alternate Administrator was assigned the administrator’s duties and responsibilities [HSLG.3.I/L651]; failed to ensure that clinical competencies were assessed on hire [HSRM.14.I/L663]; failed to ensure that orientation was completed at time of hire [HSRM.15.I/L662]; additionally, 27% plans of care did not include patients’ and family goals and interventions based on the problems identified in the updated comprehensive assessments [HCPC.21.I/L545]; and all the hospice failed to provide substantially all core services – nursing services, medical social services, and counseling services – directly by hospice employees [HCDT.2.I/L587]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality patient care in a safe environment. This is a CMS CONDITION LEVEL deficiency.

It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document reviews, interviews, and personnel records review. The hospice did not ensure that if the administrator was not available, another individual was assigned the administrator’s duties and responsibilities as defined in policy and procedure. The hospice's job description "Administrator" stated in part, Qualifications: A person who is a licensed physician or registered nurse or has training and experience in health services administration and at least two years’ experience in supervisory or administration experience in Hospice or related health programs". Review of hospice administrative documents and personnel records revealed the hospice did not designate an Alternate Administrator. During an interview on 10/26/22, the Administrator/Medical Director stated, "We do not have an Alternate Administrator." The Administrator/Medical Director presented the Licensed Vocational Nurse/Administrative Support (Staff 4) as the designated Alternate Administrator on 10/27/22. A review of the personnel record revealed Staff 4 did not qualify as the Alternate Administrator, as per the hospice’s policy. During interview 10/27/22, the Administrator/Medical Director stated an Alternate Administrator had not been designated during 2020, 2021 and 2022. Review of personnel records and interview revealed a missing designated Alternate Administrator. During interview 10/26/22, the Administrator/Medical Director stated, "We do not have an Alternate Administrator". On 10/27/22, the Administrator/Medical Director presented "LPN/Administrative Support" (Staff 4) as the designated Alternate Administrator. Review of the personnel record for (Staff 4) revealed the "LPN/Administrative Support" nurse did not qualify as the Alternate Administrator, as required in agency policy. Job Description "Administrator" included in part, "Qualifications: A person who is a licensed physician or registered nurse or has training and experience in health services administration and at least two years experience in supervisory or administration experience in Hospice or related health programs". During interview 10/27/22, the Administrator/Medical Director stated an Alternate Administrator has not been designated during 2020, 2021 and 2022.

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: the needs and concerns of patients and families coping with a terminal illness and 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. 1 of 7 (14%) personnel records reviewed of employees hired in the past three years revealed the hospice did not ensure an initial orientation was completed at time of hire. Staff 3: Review of the personnel record for the registered nurse with a contract effect date of 6/30/21 revealed the record included an orientation checklist that was not completed, the form was blank. There was no evidence that an initial orientation was completed. During an interview and a joint review of the record on 10/26/22, the Administrator reviewed and confirmed the initial orientation checklist was not completed.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by a review of interviews and personnel records. 2 of 6 (33%) personnel records reviewed of individuals providing care, including volunteers providing services revealed the hospice did not ensure the skills and competencies of all individuals providing care, including volunteers providing services were assessed. Staff 3: Review of the personnel record for the registered nurse (RN) with a contract effect date of 6/30/21, revealed the record did not include evidence of a nursing skills competency as of 10/26/22. Staff 2: Review of the personnel record for the RN with a contract effect date of 8/27/22, revealed the record did not include evidence of a nursing skills competency as of 10/26/22. Interview with the Administrator on 10/26/22 confirmed the aforementioned.

It is required that a hospice may contract for medical director services with either a self-employed physician; or a physician employed by a professional entity or physician group. The contract specifies the physician who assumes the medical director responsibilities and obligations. This standard was not met as evidenced by a review of personnel records, interviews and document reviews which revealed the hospice did not ensure contracts were in place for the contracted Medical Director and Alternate Medical Director. Staff 10: Review of the personnel record for the Alternate Medical Director revealed a missing contract. The agency was unable to provide the contract for the Alternate Medical Director. During an interview on 10/26/22, the Administrator/Medical Director stated the Alternate Medical Director had a contracted effective date of 1/1/20. On 10/27/22, the Administrator/Medical Director confirmed she was unable to locate the contract for the Alternate Medical Director. Staff 1: Review of the personnel record for the Medical Director revealed a missing contract. The agency was unable to provide the contract for the Medical Director. During interview 10/26/22, the Administrator/Medical Director stated she was under contract with an effective date of 1/1/16. On 10/27/27, the Administrator/Medical Director stated she was unable to locate her contract for Medical Director of the hospice.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 1 of 5 (20%) clinical records reviewed of patients in their third or subsequent benefit periods requiring face to face visits revealed missing face to face visits from the hospice physician or hospice nurse practitioner. As stated in 42 CFR § 418.22 "(4) Face-to-face encounter. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care." Clinical Record #7: was reviewed and identified the patient elected hospice care on 10/1/20. There was no evidence of face-to-face visits by the physician or nurse practitioner for the third, fourth and fifth benefit periods. The patient was recertified for the 3rd benefit period dated 3/30/21 through 5/28/21, the 4th benefit period 5/29/21 through 7/27/21 and the 5th benefit period 7/28/21 through 9/25/21. During an interview and a joint record review, the Administrator/Medical Director stated, "The missing face to face visits for the 3rd, 4th and 5th benefit periods are not documented in the clinical record." 418.22 (4) Face-to-face encounter. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.

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. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 11 of 11 (100%) clinical records reviewed revealed the hospice did not ensure that all entries in the patient clinical record were appropriately authenticated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice's policy #11.4.1 "Patient Record Entries: Authentication", (revised June 2019) stated in part, "All entries in the clinical record will be authenticated by staff by signing first name or initial, last name and title." Clinical Record 1: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 2: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 3: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 4: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 5: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 6: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 7: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 8: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 9: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 10: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. Clinical Record 11: The physician's orders, plans of care, assessments and visit notes in the electronic medical record did not include the title of the staff performing the care/service in the electronic medical record signature. During an interview on 10/26/22, the Administrator/Medical Director confirmed the finding. On 10/27/22 the Licensed Vocational Nurse/Administrative Assistant stated the staff titles were added to the records. During interview 10/26/22, the Administrator/Medical Director stated "There must be a glitch in the electronic medical record and we will be following up to make this correction". This finding was reported to the Administrator/Medical Director on 10/26/22. During interview 10/27/22, the Administrator/Medical Director confirmed that staff titles had now been added into the electronic medical records. During interview 10/27/22, the LPN who was designated by the Administrator to review clinical clinical records stated "yes, the staff titles are now added to the list of staff in the electronic medical record and now all staff signatures in the clinical record even before today have titles". Policy, "Patient Record Entries: Authentication", Policy number 11.4.1. revised June 2019, included in part, "All entries in the clinical record will be authenticated by staff by signing first name or initial, last name and title".

It is required that a physician is a Doctor of Medicine or Osteopathy legally authorized to practice medicine by the state in which he or she practices, and who is acting within the scope of his or her license. This standard was not met as evidenced by document reviews, interviews and personnel records review. 1 of 2 (50%) personnel records reviewed of the Medical and the Alternate Medical Directors revealed the hospice did not ensure that physicians were legally authorized to practice medicine by the state in which such function or action is performed. Staff 10: The Alternate Medical Director with a contract effective date of 1/1/20, did not have a personnel record or contract to review. There was no evidence the physician's license was verified. During an interview on 10/27/22, the Medical Director stated that she could not locate the missing Alternate Medical Director's personnel record and contract.

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 document reviews and interviews. 2 of 5 (40%) contracts reviewed revealed the hospice did not ensure hospice contracts required all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Contract #3: Review of the General In Patient/Respite contract signed 11/21/19, revealed the missing requirement that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Contract #5: Review of the Physical Therapy, Occupational Therapy and Speech Therapy contract signed 2/24/20, revealed the missing requirement that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. During an interview on 10/26/22, the Administrator/Medical Director confirmed the finding. During interview 10/26/22, the Administrator/Medical Director stated a contract addendum would be completed to include the required background check of all contracted employees who have direct patient contact or access to patient record.

It is required that the hospice and its staff operate and provide care and services in compliance with local, state, and federal law and regulation related to the health and safety of patients. This standard was not met as evidenced by document reviews, interviews and personnel records. The state's Administrative Code, read in part, "An Administrator shall designate in writing a RN as Director of Nursing who has the authority and responsibility for managing nursing services provided by the Hospice." Review of personnel records and interview revealed the hospice did not have a Nursing Director, Alternate Nursing Director, and Alternate Administrator. During an interview on 10/26/22, the Administrator/Medical Director stated, "No we do not have a Nursing Director, Alternate Nursing Director and Alternate Administrator...The previous Nursing Director resigned in September this year and we looking for a new Director and have not designated the Nursing Director or Alternate Nursing Director yet...We did not notify the State that the Nursing Director resigned and who was designated as the new Nursing Director and Alternate Nursing Director." During interview, the HR Coordinator stated the previous Nursing Director was hired 4/13/22 and resigned 9/5/22. Review of personnel records and interview revealed a missing Nursing Director, Alternate Nursing Director and Alternate Administrator. During interview 10/26/22, the Administrator/Medical Director stated, "No we do not have a Nursing Director, Alternate Nursing Director and Alternate Administrator", "The previous Nursing Director resigned in September this year and we looking for a new Director and have not designated the Nursing Director or Alternate Nursing Director yet" and "We have not notified the State that the Nursing Director resigned and who was designated as the new Nursing Director and Alternate Nursing Director". During interview, the HR Coordinator stated the previous Nursing Director was hired 4/13/22 and resigned 9/5/22 and that she did not have a personnel record for a Alternate Nursing Director. On 10/27/22, the Administrator/Medical Director presented a signed statement, "(Hospice) Interim Nurse Director", "I (administrator) herby designate (Staff 2) to assume duties and responsibilities of Nursing Director on an interim basis starting 10/27/22 until a Nursing Director permanent employee is hired", dated and signed by (Staff 2) and Administrator on 10/27/22. Agency policy job description for nursing "Director" reviewed and included in part, "Qualifications: graduate from an accredited school of nursing and currently licensed as a registered nurse to practice in the state". (State) Administrative Code, Title 9, Chapter 10, Article 6 Hospices, R9-10-603(D)(2), "An Administrator shall designate shall designate in writing a RN as Director of Nursing who has the authority and responsibility for managing nursing services provided by the Hospice".

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families. This standard was not met as evidenced by interviews and review of personnel records. 2 of 10 (20%) personnel records reviewed revealed the hospice did not ensure that individuals eligible to be fully vaccinated, were fully vaccinated, or there is evidence of an individual having a pending request for, or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. Staff #2: Review of the personnel record of the Registered Nurse with the contract effective date of 8/27/22, revealed no evidence of a COVID vaccination or exemption to date. During an interview on 10/27/22, the Administrator confirmed the nurse was not vaccinated. Staff #10: The Alternate Medical Director with the contract effective date of 1/1/20, did not provide evidence of a COVID vaccination or exemption. The hospice did not present a personnel record or documents for the contracted Alternate Medical Director. During an interview on 10/27/22, the Administrator confirmed the finding.