Every finding on record at Sheer Love Hospice

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. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, the agency did not ensure the patient's individual written plan of care included goals and interventions based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUING PRIOR REQUIRED ACTION. Clinical Record 2: The patient elected the hospice benefit on 10/01/2023 with a terminal diagnosis of heart disease. The individualized plan of care did not include a goal(s) or intervention(s) related to the management of the patient's cardiac diagnosis. Clinical Record 3: The patient elected the hospice benefit on 10/01/2023 with a terminal diagnosis of Alzheimer’s disease. The individualized plan of care did not include a goal(s) or intervention(s) related to the management of the patient's Alzheimer’s diagnosis. Clinical Record 5: The patient elected the hospice benefit on 01/11/2024 with a terminal diagnosis of Alzheimer’s disease. The individualized plan of care did not include a goal(s) or intervention(s) related to the management of the patient's Alzheimer’s diagnosis. During an interview on 02/26/2024, the Director of Clinical Services confirmed that goals and interventions based on the problems identified in the initial and comprehensive assessments were not listed on the patients' plans of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 3 of 5 (60%) clinical records reviewed revealed the agency did not ensure the patient's individual written plan of care (POC) included goals and interventions based on problems identified in the initial and updated comprehensive assessments.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, the hospice did not ensure that the physician completed a written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. Clinical Record 1: The patient elected the hospice benefit on 05/13/2023. The clinical record contained no documented evidence of a written and signed certification of terminal illness for the first benefit period dated 05/13/2023 through 08/10/2023, as of the date of the clinical record review on 02/26/2024. Clinical Record 2: The patient elected the hospice benefit on 10/01/2023. The clinical record contained no documented evidence of a written and signed certification of terminal illness for the first benefit period dated 10/01/2023 through 12/29/2023, as of the date of the clinical record review on 02/26/2024. Clinical Record 3: The patient elected the hospice benefit on 10/01/2023. The clinical record contained no documented evidence of a written and signed certification of terminal illness for the first benefit period dated 10/01/2023 through 12/29/2023, as of the date of the clinical record review on 02/26/2024. During an interview on 02/26/2024, the Director of Clinical Services confirmed the finding and stated they will be contacting and reeducating their Medical Director. In 3 of 5 (60%) clinical records reviewed revealed the hospice did not ensure that a written certification of terminal illness was completed.

It is required that the recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed requiring a recertification of terminal illness, the agency did not ensure the recertification was completed. THIS IS A CONTINUING PRIOR REQUIRED ACTION. Clinical Record 2: The patient elected the hospice benefit on 10/01/2023. The clinical record contained no documented evidence of a written and signed recertification of terminal illness for the patient’s second benefit period dated 12/30/2023thorugh 03/28/2024, as of the date of the clinical record review on 02/26/2024. Clinical Record 3: The patient elected the hospice benefit on 10/01/2023. The clinical record contained no documented evidence of a written and signed recertification of terminal illness for the second benefit period dated 12/30/2023 through 03/28/2024, as of the date of the clinical record review on 02/26/2024. Clinical Record 4: The patient elected the hospice benefit on 09/25/2023. The clinical record contained no documented evidence of a written and signed recertification of terminal illness for the second benefit period dated 12/24/2023 through 03/22/2024, as of the date of the clinical record review on 02/26/2024. During an interview on 02/26/2024, the Director of Clinical Services confirmed the finding and stated the physician needed reeducation. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 3 of 5 (60%) clinical records reviewed requiring a recertification of terminal illness revealed the agency did not ensure the recertification was completed.

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who revoked the hospice benefit, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. Clinical Record 1: The clinical record contained no documented evidence that a copy of the discharge summary was sent to the patient's attending physician following the patient’s revocation of the hospice benefit. Clinical Record 2: The clinical record contained no documented evidence that a copy of the discharge summary was sent to the patient's attending physician following the patient’s revocation of the hospice benefit. During an interview on 02/26/2024, the Director of Clinical Services confirmed that the hospice was not able to provide documentation that the discharge summaries were sent to the patients’ attending physicians. In 2 of 2 (100%) clinical records reviewed of patients who revoked the hospice benefit revealed the agency did not ensure that a copy of the hospice discharge summary was forwarded to the patient's attending physician.

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 development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment, and the documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by document review, interview and observation. 3 of 3 (100%) home visits revealed the agency did not ensure that an individualized disaster plan was developed for each patient as part of the comprehensive assessment. Agency Policy #7-001.1, "Emergency Management Plan (Revised: 11/2020)," stated in part, "Procedure: 9. Individualized plans for patients during a natural or man-made disaster will be included as part of the comprehensive patient assessment." Home Visit 4: The patient elected the hospice benefit on 1/25/23. During the patient observation visit on 5/10/23, a review of the agency information in the patient's home did not include documented evidence of an individualized Emergency Plan. The information in the patient's home included general emergency information. Home Visit 5: The patient elected the hospice benefit on 2/6/23. During the patient observation visit on 5/10/23, a review of the agency information in the patient's home did not include documented evidence of an individualized Emergency Plan. The information in the patient's home included general emergency information. Home Visit 6: The patient elected the hospice benefit on 4/25/23. During the patient observation visit on 5/9/23, a review of the agency information in the patient's home did not include documented evidence of an individualized Emergency Plan. The information in the patient's home included general emergency information. In an interview on 5/10/23, the Administrator/Director of Patient Care Services reviewed and agreed that the agency was not ensuring compliance with developing and reviewing an individualized Emergency Plan with the patient/family.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 8 (12%) clinical records reviewed revealed the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment. Agency Policy #1-021, "Bereavement Assessment (Dated: 11/2020)," stated in part, "Procedure: 1. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator." Clinical Record 8: The patient elected the hospice benefit on 12/12/22. The clinical record did not include documented evidence of a completed initial bereavement assessment. In an interview on 5/11/23, the Administrator/Director of Patient Clinical Services reviewed the findings and agreed that the record did not include documentation of an initial bereavement assessment.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by clinical record review, document review and interview. 4 of 8 (50%) clinical records reviewed revealed the agency did not ensure the registered nurse (RN) provided patient visits at the frequency ordered on the interdisciplinary group (IDG) plan of care (POC). Document 1: Policy #9-017, "The Plan of Care (Dated: 11/2020)," stated in part, "Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care." Clinical Record 1: The patient elected the hospice benefit on 1/25/23. The IDG plan of care (POC) dated 1/25/23 included a registered nurse (RN) visit frequency order of 1 time every other week. The record did not include documented evidence of an RN visit the week of 2/5/23. The clinical record included documentation of RN visits on 1/25/23, 2/8/23, 2/22/23, 3/22/23, 3/29/23 (declined visit), 4/6/23, 4/13/23, and 4/18/23. There is no documented evidence that an RN visit was provided the week of 4/30/23. Clinical Record 2: The patient elected the hospice benefit on 2/6/23. The IDG POC dated 2/6/23 included an RN visit frequency order of 1 time every other week. The clinical record did not include documented evidence of an RN visit the weeks of 3/5/23, 4/2/23, and 4/16/23. The clinical record included documentation of RN visits on 2/6/23, 2/20/23, 3/22/23, 5/5/23, and 5/10/23 (prn visit). Clinical Record 4: The patient elected the hospice benefit on 2/17/23. The IDG POC dated 2/17/23 included an RN visit frequency order of 1 time every other week. The clinical record did not include documented evidence of an RN visit the weeks of 3/12/23, 3/26/23, and 4/9/23. The clinical record included documentation of RN visits on 2/17/23, 2/22/23 (prn visit), and 3/3/23. The patient revoked the hospice benefit on 4/14/23. Clinical Record 7: The patient elected the hospice benefit on 12/12/22. The IDG POC dated 3/9/23 included an RN visit frequency order of 1 time every other week. The clinical record included documented evidence of RN visits on 2/24/23 and 3/1/23, which was the last RN visit documented as of the date of the site visit record review on 5/11/23. The clinical record included documented evidence of weekly licensed vocational nurse visits. In an interview on 5/11/23, the Administrator/Director of Patient Care Services reviewed and agreed the agency did not ensure compliance with the ordered RN visit frequencies as identified in the findings.

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. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 8 (25%) clinical records reviewed revealed the agency did not ensure the patient's individual written plan of care (POC) included goals and interventions based on problems identified in the initial and updated comprehensive assessments. Agency Policy #9-017, "The Plan of Care (Dated: 11/2020)," stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments. . . The plan will focus on identified problems, goals, and interventions." Clinical Record 1: The patient elected the hospice benefit on 1/25/23. The patient's primary diagnosis was Atherosclerotic Heart Disease of Native Coronary Artery. The patient's plan of care (POC) did not include documentation of a goal or intervention(s) related to the management of the patient's cardiac diagnosis. Clinical Record 3: The patient elected the hospice benefit on 4/25/23. The patient's primary diagnosis was Atherosclerotic Heart Disease of Native Coronary Artery. The patient's POC did not include documentation of a goal or intervention(s) related to the management of the patient's cardiac diagnosis. In an interview on 5/11/23, the Administrator/Director of Patient Care Services reviewed and agreed the patients' records did not include evidence of goals and interventions in the POC related to the patients' diagnoses.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 8 (25%) clinical records reviewed revealed the agency did not ensure the interdisciplinary group (IDG), in collaboration with the individuals attending physician, reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days. Agency Policy #9-017, "The Plan of Care (Dated: 11/2020)," stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days." Clinical Record 6: The patient elected the hospice benefit on 1/21/23. The clinical record included documented evidence of an IDG meeting on: 1/21/23, 1/26/23, 2/9/23, and 2/23/23. The patient revoked the hospice benefit on 3/28/23. The clinical record did not include documented evidence of an IDG meeting the weeks of 3/5/23 and 3/19/23. Clinical Record 8: The patient elected the hospice benefit on 12/12/22. The record included documented evidence of one IDG meeting on 12/12/22. The clinical record did not include documented evidence of IDG meetings the weeks of 12/25/22, 1/8/23, 1/22/23, and 2/5/23. The patient was discharged for no longer meeting the Hospice benefit requirements on 2/9/23. in an interview on 5/11/23, the Administrator/Director of Patient Clinical Services reviewed and agreed that documentation of the IDG meeting(s) listed in the findings were missing from the clinical records.

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. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 4 (25%) clinical records requiring a recertification of terminal illness revealed the agency did not ensure the recertification was completed no later than two (2) calendar days after the first day of each benefit period. Agency Policy #1-007, "Certification of Terminal Illness (Dated: 11/2020)," stated in part, "Procedure: 5. A subsequent recertification . . . A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period." Clinical Record 7: The patient elected the hospice benefit on 12/12/22. The certification of terminal illness (CTI) was present for the first benefit period. The clinical record did not include documented evidence of a written and signed recertification for the second benefit period 3/12/23 - 6/9/23 as of the date of the clinical record review on 5/11/23. In an interview on 5/11/23, the Administrator/Director of Patient Care Services (DCPS) reviewed and agreed the CTI for the second benefit period was missing in the clinical record identified in the findings.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician, a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. 4 of 4 (100%) clinical records reviewed of patients who revoked the hospice benefit or were no longer eligible to receive the hospice benefit, revealed the agency did not ensure that a copy of the hospice discharge summary was forwarded to the patient's attending physician. Agency Policy #1-024, "Revocation of Hospice Benefit (Dated: 11/2020)," stated in part, "Procedure: 3. The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician." Agency Policy #1-025, "Discharge from Hospice Program (Dated: 11/2020)," stated in part, "Procedure: 9. A copy of the discharge summary will be sent to the attending physician. If requested, the patient's clinical record will be provided." Clinical Record 4: The patient elected the hospice benefit on 2/17/23. The patient revoked the hospice benefit on 4/14/23. The clinical record did not include documented evidence that a copy of the discharge summary was sent to the patient's attending physician. Clinical Record 5: The patient elected the hospice benefit on 2/12/22. The patient revoked the hospice benefit on 3/28/23. The clinical record did not include documented evidence that a copy of the discharge summary was sent to the patient's attending physician. Clinical Record 6: The patient elected the hospice benefit on 1/21/23. The patient revoked the hospice benefit on 3/28/23. The clinical record did not include documented evidence that a copy of the discharge summary was sent to the patient's attending physician. Clinical Record 8: The patient elected the hospice benefit on 12/12/22. The patient was discharged for no longer being qualified to receive the hospice benefit on 2/9/23. The clinical record did not include documented evidence that a copy of the discharge summary was sent to to the patient's attending physician. In an interview on 5/11/23, the Administrator/Director of Patient Care Services reviewed and agreed with the findings that the agency did not forward the discharge summary to the patient's attending physician for the above patients that either revoked the hospice benefit or were discharged for no longer being qualified to receive the hospice benefit.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Corrected on site.

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Corrected on site. Patient 1: The RN documents in the care plan that patient was educated to take amlodipine 5mg po daily and metoprolol succinate ER 1 tab po twice daily. The medications are not listed on the POC or the medication profile. Per RN discussion is was an error. Pt is not on these two medications.