Every finding on record at Sherman Oaks Hospice Care Group, Inc

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, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure the medication profile and medication review included the patient’s current medications. Home Visit 2/Clinical Record 11: The patient elected the hospice benefit on 01/17/2025 with diagnoses of cerebral atherosclerosis and protein calorie malnutrition. The patient resided in a group home. During the home visit observation on 02/12/2025 with the Chaplain (Personnel Record 8), a medication review was completed by comparing the hospice medication profile printed on 02/11/2025 to the medication list in the group home. The group home medication list included Hemp Extract, one at bedtime, started 03/20/2024, and Fish Oil, one at bedtime, with no start date. The group home caregiver verified that the patient has been receiving these supplements. The hospice medication profile did not include Hemp Extract and Fish Oil, and the medications were not included in the patient’s medication review. Home Visit 3/Clinical Record 5: The patient elected the hospice benefit on 08/29/2024 with diagnoses of severe protein-calorie malnutrition, dysphagia, convulsions, diverticula of large intestine, and dementia. The patient resided in a Skilled Nursing Facility [SNF]. During the home visit observation on 02/12/2025 with the Certified Home Health Aide (CHHA) (Personnel Record 9), a medication review was completed by comparing the hospice medication profile printed on 02/11/2025 to the medication list in the SNF. The SNF medication list included Nystatin Extended Powder 100,000 units/gram, apply to the left axilla three times a day, cleanse with normal saline [NS], pat dry, sprinkle powder, LOA [leave open to air]. The hospice medication profile did not include Nystatin. The hospice medication profile included Ibuprofen 200mg 1 tab every 4 hours as needed for moderate pain (4-7). The SNF medication list did not include Ibuprofen. The Licensed Vocational Nurse at the SNF verified that Ibuprofen was not an active order, and the Nystatin was an active order in the patient's SNF medical record. During a joint record review and interview on 02/12/2025, the Director of Patient Care Services confirmed that the medications were not included in the medication review and the medication profiles did not include the patient’s current medications.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency Policy #619 Hand Hygiene Technique, revision date 05/20/2019, required in part, "Handwashing is needed for routinely decontaminating hands in the following clinical situations: after contact with body fluids or excretions, mucous membranes, a non-intact skin, and wound dressings, even if hands are not visibly soiled; when moving from a contaminated body site to a clean body site during patient care... and after removing gloves... Gloves and Hand Hygiene... Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient." Home Visit 1: During the home visit observation on 02/12/2025 with the Registered Nurse (RN) (Personnel Record 6), the RN was observed to clean the unstageable heel wound, apply calcium alginate with Medihoney, and cover it with a foam dressing. The RN did not change the gloves and decontaminate hands between cleaning the wound and applying clean dressings. Home Visit 3: During the home visit observation on 02/12/2025 with the Certified Home Health Aide (CHHA) (Personnel Record 9), the CHHA was observed to change gloves three times while providing patient care. The CHHA did not wash/decontaminate hands between glove changes. During an interview and joint review of findings on 02/12/2025, the Director of Patient Care Services agreed that staff did not follow the agency’s hand hygiene policy.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure documentation that nursing care was provided under the supervision of a Registered Nurse. Clinical Record 1: The patient elected the hospice benefit on 05/09/2024 with diagnoses of cerebral atherosclerosis, dysphagia, history of falling, syncope and collapse, lack of coordination, and pacemaker. Clinical record review revealed the Licensed Vocational Nurse [LVN] provided skilled nursing visits on 06/06/2024, 06/18/2024, 06/27/2024, 07/02/2024, 07/09/2024, 07/16/2024, 07/23/2024, 07/30/2024, 08/01/2024, 08/08/2024, 10/26/2024, 11/12/2024, 12/24/2024, and 12/27/2024. The Registered Nurse [RN] documented completion of skilled nursing visits that included supervisory visits on 06/11/2024, 06/20/2024, 06/25/2024, 07/04/2024, 07/18/2024, 08/06/2024, 08/14/2024, 08/19/2024, 08/28/2024, 09/04/2024, 10/30/2024, 11/06/2024, 11/15/2024, 11/20/2024, 01/08/2025, 01/15/2025, and 01/29/2025. LVN supervisory documentation was not included in the nursing supervisory visit notes completed by the RN. Clinical Record 19: The patient elected the hospice benefit on 04/02/2024 with diagnoses of chronic atrial fibrillation, hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, and dialysis. Clinical record review revealed the LVN provided skilled nursing visits on 05/24/2024, 06/07/2024, 06/10/2024, 07/06/2024, 07/18/2024, 07/20/2024, and 07/21/2024. The Registered Nurse [RN] documented completion of skilled nursing visits that included supervisory visits on 05/27/2024, 06/14/2024, 06/24/2024, and 07/01/2024. LVN supervisory documentation was not included in the nursing supervisory visit notes completed by the RN. The clinical record included a LVN supervisory visit dated 05/20/2024 that did include documentation of LVN supervision. During a joint clinical record review and interview on 02/14/2025, the Director of Patient Care Services agreed that the licensed vocational nurses were not supervised per the agency process. The Director of Patient Care Services stated that there was no policy stating a specific timeframe but that 30 days is the process that is followed and LVN supervision should be documented in the RN Supervisory Visit notes.

It is required that medical social services are provided by a qualified social worker: based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed with medical social services provided, the agency did not ensure medical social services were provided per the plan of care. Clinical Record 2: The patient elected the hospice benefit on 10/10/2024 with diagnoses of cirrhosis of the liver, hepatic encephalopathy, atrial fibrillation, pacemaker, hypertension, and chronic diastolic heart failure. The plan of care/Interdisciplinary Group reviews dated 10/22/2024, 11/05/2024, 11/19/2024, and 12/03/2024 included documentation that the Medical Social Worker [MSW] was to provide a social service visit to the patient one time per month and three as needed visits were also included. Clinical record review revealed no documented evidence of that the MSW provided a visit to the patient for the month of November from 11/01/2024 to 11/30/2024. The clinical record did not include a missed visit note for the month of November. During a joint record review and interview on 02/13/2025, the Director of Patient Care Services agreed that there was no documented evidence that a social work visit was provided during the times identified.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse [RN] completed an aide supervisory visit no less frequently than every 14 days. Clinical Record 1: The patient elected the hospice benefit on 05/09/2024 with diagnoses of cerebral atherosclerosis, dysphagia, history of falling, syncope and collapse, lack of coordination, and pacemaker. Clinical record review revealed hospice aide services were provided twice a week, with the first aide visit dated 05/13/2024. The RN documented an aide supervisory visit on 12/17/2024 and the next aide supervisory visit was dated 01/08/2025, a total of 22 days after the 12/17/2024 supervisory visit and 8 days outstanding. Clinical Record 2: The patient elected the hospice benefit on 10/10/2024 with diagnoses of cirrhosis of the liver, hepatic encephalopathy, atrial fibrillation, pacemaker, hypertension, and chronic diastolic heart failure. Clinical record review revealed hospice aide services were provided three times a week, with the first aide visit dated 10/11/2024. The RN documented an aide supervisory visit on 12/18/2024 and the next aide supervisory visit was dated 01/09/2025, a total of 22 days after the 12/18/2024 supervisory visit and 8 days outstanding. Clinical Record 3: The patient elected the hospice benefit on 09/18/2024 with diagnoses of cerebral atherosclerosis, atrial fibrillation, hypertension, anemia, dementia, depression, anxiety, chronic obstructive pulmonary disease. Clinical record review revealed hospice aide services were provided twice a week, with the first aide visit dated 09/20/2024. The RN documented an aide supervisory visit on 11/25/2024 and the next aide supervisory visit was dated 12/11/2045, a total of 16 days after the 11/25/2024 supervisory visit and 2 days outstanding. The RN also documented an aide supervisory visit on 01/20/2025 and the next aide supervisory visit was dated 02/05/2025, a total of 16 days after the 01/20/2025 supervisory visit and 2 days outstanding. During a joint clinical record review and interview on 02/14/2025, the Director of Patient Care Services confirmed that the Registered Nurse did not make on-site aide supervisory visits to the patient’s home no less frequently than every 14 days.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with volunteer services requested, the agency did not ensure that volunteer services were provided to patients/families as noted in the plan of care. Clinical Record 5: The patient elected the hospice benefit on 08/29/2024 with diagnoses of severe protein-calorie malnutrition, dysphagia, convulsions, diverticula of large intestine, and dementia. Clinical record review revealed the nursing comprehensive assessment dated 08/29/2024 included documentation for “Referral for: Volunteer” services. The Plan of Care/Interdisciplinary Group [POC/IDG] reviews dated 09/24/2024 and 11/19/2024 included documentation "Frequency of Visit: Volunteer: accepted." The POC/IDG reviews dated 10/22/2024, 11/5/2024, 12/03/2024, 12/17/2024, 01/14/2024, and 01/28/2024 included documentation that "IDG Discussion/Updated Comprehensive Assessment Review: Nursing: VOL [volunteer]: accepted." The clinical record contained no documented evidence that volunteer services were provided to the patient. During a joint clinical record review and interview on 02/13/2025, the Director of Patient Care Services agreed that the agency did not provide a volunteer as documented in the record.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the clinical record included physician orders for services provided. Clinical Record 6: The patient elected the hospice benefit on 01/16/2024 with diagnoses of chronic obstructive pulmonary disease, hypertension, and oxygen dependence. The clinical record included a Volunteer Assignment dated 06/18/2024 and Volunteer visit notes dated 06/18/2024, 06/21/2024, 06/25/2024, 06/27/2024, 07/05/2024, 07/09/2024, 07/11/2024, 07/16/2024, and 07/18/2024. However, there was no documented evidence in the clinical record of a physician order for volunteer services. During a joint clinical record review and interview on 02/13/2025, the Director of Patient Care Services agreed the record did not include a physician order for the volunteer visits.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles. A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. This standard was not met as evidenced by interview and personnel record review. In 1 of 8 (12%) records reviewed revealed the agency did not ensure that all employees (including non-employee staff) had evidence of compliance with the emergency preparedness training. Personnel Record 7: The personnel record review revealed that this volunteer had an initial hire date of 01/23/2024 and had both patient care and administrative volunteer roles. The record did not include evidence of emergency preparedness training. The Clinical Operations Supervisor (personnel record 4) and the Volunteer Coordinator (personnel record 5) reported that emergency preparedness is part of the volunteer orientation but were unable to provide documented evidence that this was completed for this individual.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 6 (50%) records reviewed revealed the agency did not ensure that the initial comprehensive assessments included the social workers' psychosocial assessment, within the five-day requirement. Clinical Record 3: The patient elected the hospice benefit on 02/24/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The record contained documentation that the Medical Social Work (MSW) services were accepted but the family had declined the visit until 03/04/2024. Documentation for the MSW initial assessment stated the visit was initiated on 03/04/2024 at 1:00pm and ended at 2:00pm. All areas of the assessment were left blank. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024 with a diagnosis of malignant neoplasm of the pancreas. Documentation for the MSW initial assessment stated the visit was initiated on 02/22/2024 at 2:15pm and ended at 2:45pm. All areas of the assessment were left blank. Clinical Record 5: The patient elected the hospice benefit on 01/20/2024 with a diagnosis of COPD. The plan of care contained orders for the social worker to conduct an initial assessment. The record did not contain evidence that the initial social worker assessment had been completed or documentation to support why the visit had not been made. Personnel Record 4: Joint record reviews were conducted on 03/26/2024 with the Clinical Operations Specialist who confirmed that these records did not have evidence that the psychosocial comprehensive assessments were completed within the five-day requirement. The MSW was contacted regarding these visits, and it was reported that "she was checking her notebook but thought the visits had been made and documented." No additional information was provided at the time of the exit conference.

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) records reviewed revealed the agency did not ensure the written plans of care contained specific interventions based on the problems identified in the comprehensive assessments. Clinical Record 1: The nursing initial comprehensive assessment, dated 10/04/2023, reported a diagnosis of cerebral atherosclerosis and noted a recent history of falls. The assessment included a fall risk score of 18 which equaled "High Risk". The nursing visit notes from 02/29/2024 stated, "Fall: moderate to high risk for falls. Fall prevention interventions in place. There was no report of a fall or near fall." The plan of care, effective from 10/04/2023 to current, did not include any problems, goals, or interventions related to fall prevention, or fall safety measures. This record was reviewed jointly (on 03/26/2024) with the Clinical Operations Supervisor (personnel record 4) who agreed that that care plan did not address the fall/safety risk of the patient, "and it should have." Clinical Record 3: The spiritual initial comprehensive assessment, dated 02/29/24, contained check box documentation and revealed that under the heading: "patient spiritual distress/concern" the problem checked was "alienation from faith community", and under the heading "primary care giver spiritual distress/concern" the problem of "anticipatory grief" was selected. The plan of care, effective as of 02/29/2024, did not include any spiritual care problems, goals, or interventions. This record was reviewed jointly (on 03/26/2024) with the Clinical Operations Supervisor (personnel record 4) who checked the care plan and confirmed that there had not been any spiritual care plans initiated but agreed there should have been interventions to address the concerns of alienation from faith community and anticipatory grief.

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. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 6 (50%) records reviewed revealed the agency did not ensure that the plans of care were revised or updated when issues were identified. Document 5: Medical Social Services, Policy #821 (no date). Stated in part, "The social worker participates in the development of the plan of care (POC) to meet the identified needs of the patient and caregiver." Clinical Record 3: The patient elected the hospice benefit on 02/24/2024 and the initial plan of care orders included an initial assessment from the MSW (Medical Social Worker). The record review revealed that the family declined the social worker visit until 03/04/2024, however, the assessment that the MSW submitted was completely blank with the exception of the date and time the assessment was made. During the interdisciplinary team (IDT) meeting, held on 2/27/24, the MSW documented "continuing to assess patients coping skills, disease progress, and safety. Ongoing support and education to patient's son and family related patients disease progress and hospice care. Final arrangement will be completed." The record did not include documentation to indicate how the MSW assessed this information, and the plan of care was not updated during or following this meeting to include any psychosocial related problems, goals, or interventions. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024 and the initial plan of care orders included an order for an initial assessment from the MSW. The record review revealed that assessment that the MSW submitted on 02/22/2024 was completely blank with the exception of the date and time the assessment was made. During the IDT meeting, held on 2/27/24, the MSW documented "continuing to assess patients coping skills, disease progress, and safety. Ongoing support and education to patient's daughter and family related patients' disease progress and hospice care. Final arrangement will be completed." The record did not include documentation to indicate how the MSW assessed this information, and the plan of care was not updated during or following this meeting to include any psychosocial related problems, goals, or interventions. Clinical Record 5: The patient elected the hospice benefit on 01/20/2024 and the initial plan of care included an order for an initial assessment from the MSW. The clinical record did not include any documentation that the MSW completed the initial assessment nor any documentation to support why the initial visit was not completed. During the IDT meetings, held on 1/31/24 and 02/14/2024, the MSW documented "continuing to assess patients coping skills, disease progress, and safety. Ongoing support and education to patient's conservator and SNF (skilled nursing facility) staff related patients' disease progress and hospice care. Final arrangement will be completed." The record did not include documentation to indicate how the MSW assessed this information, and the plan of care was not updated during or following these meetings to include any psychosocial related problems, goals, or interventions. Furthermore, for the IDT meeting conducted on 02/27/2024 the MSW documented "patient expired and all care plans closed" there were no psychosocial care plans that had been opened. Personnel Record 4: During the joint record review, on 03/26/2024, the Clinical Operations Supervisor confirmed that these records did not include completed assessments from the MSW, nor did they contain updated or revised care plans based on the IDT meeting notes. The Clinical Operations Supervisor, administrator, and alternate administrator also agreed that the MSW should be writing individualized IDT notes that accurately describe the psychosocial needs of the patient.

It is required that medical social services are provided per the plan of care. The psychosocial assessment addresses: The patient’s and the family’s adjustment to the terminal illness; The social and emotional factors related to the terminal illness; The presence or absence of adequate coping mechanisms; Family dynamics and communication patterns; Financial resources and any constraints; The caregiver’s ability to function effectively; Obstacles and risk factors that may affect compliance with the plan of care; Family support systems to facilitate coping with end-of-life issues. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 6 (33%) records reviewed revealed the agency did not ensure the social worker documented all components of the psychosocial assessment. Document 5: Medical Social Services, Policy #821 (no date) stated in part, "MSW (Medical Social Worker) visit notes to be completed within 48 hours." Clinical Record 3: The patient elected the hospice benefit on 02/24/2024 with a diagnosis of chronic obstructive pulmonary disease. The record contained documentation that the Medical Social Work (MSW) services were accepted but the family had declined the visit until 03/04/2024. Documentation for the MSW initial assessment stated the visit was initiated on 03/04/2024 at 1:00pm and ended at 2:00pm. All areas of the assessment were left blank. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024 with a diagnosis of malignant neoplasm of the pancreas. Documentation for the MSW initial assessment stated the visit was initiated on 02/22/2024 at 2:15pm and ended at 2:45pm. All areas of the assessment were left blank. Personnel Record 4: During the joint record review, on 03/26/2024, the Clinical Operations Supervisor determined that the assessments had been started within the electronic medical record (EMR) system but had not yet been completed. The MSW (personnel record 8) was contacted and stated they "didn't know what happened, I thought they were done." The EMR reporting system tracked the documentation and for these two records the visits had a red "X" which indicated the visit had been started but not completed, submitted, and approved. The Clinical Operations Supervisor further explained that all assessments, once submitted, go through an "approval process" within the EMR system which then locks the visit and is then noted with a green checkmark; it was stated that these visits had been missed in that process.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) records reviewed in which aide services were accepted revealed the agency did not ensure the hospice aide care plan included specific instructions required for the aide to perform care. Clinical Record 1: Per the initial nursing comprehensive assessment, dated 10/04/2023, the patient had a diagnosis of cerebral atherosclerosis and had a colostomy in place. The hospice aide care plan, effective from 10/4/2023 to current, included the following relevant tasks: bed bath and dressing both at every visit. The care plan did not alert the aide the patient had a colostomy in place. Personnel Record 4: During the joint clinical record review, on 03/26/2024, the Clinical Operations Supervisor, confirmed that the aide care plan did not include any guidance to the aide regarding the colostomy and stated it would be added by the RN.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) records reviewed, in which volunteer services were accepted, revealed the volunteer services were not provided per the plan of care. Clinical Record 2: The patient elected the hospice benefit on 09/09/2023 with a diagnosis of Alzheimer's disease. The plan of care included orders for volunteer visits one time per week effective 12/01/2023. For the weeks of 02/11/2024 and 02/25/2024 there were no documented visits nor was there any documentation to support why the visits were missed. Personnel Record 4: During the joint record review, the Clinical Operations Supervisor, was unable to locate any volunteer visit notes for the two weeks in question and contacted the volunteer coordinator. At the end of the site visit the Clinical Operations Supervisor reported that the volunteer coordinator could not find any documentation and thus was unsure if the visits were made or not.

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 and interview; the hospice failed as follows: to ensure that medical social services care was provided in a manner consistent with accepted standards of practices [418.100(c)/L652]; to ensure that all individuals who furnished care, including volunteers had skills and competencies tested during the initial orientation and annually thereafter consistent with agency policy [418.100(g)(3)/L663]. The cumulative effect of these systemic issues resulted in the potential for compromised quality health care and patient safety. This is a CMS CONDITION DEFICIENCY at 418.100.

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Medical social services. This requirement was not met as evidenced by clinical record review and interview. In 3 of 6 (50%) records reviewed revealed the agency did not ensure that medical social services were provided in a manner consistent with acceptable standards of practice. Clinical Record 3: The patient elected the hospice benefit on 02/24/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The record contained documentation that the Medical Social Work (MSW) services were accepted but the family had declined the visit until 03/04/2024. Documentation for the MSW initial assessment stated the visit was initiated on 03/04/2024 at 1:00pm and ended at 2:00pm. All areas of the assessment were left blank. During the interdisciplinary team (IDT) meeting, held on 2/27/24, the MSW documented "continuing to assess patients coping skills, disease progress, and safety. Ongoing support and education to patient's son and family related patients' disease progress and hospice care. Final arrangement will be completed." The record did not include documentation to indicate how the MSW assessed this information, and the plan of care was not updated during or following this meeting to include any psychosocial related problems, goals, or interventions. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024 with a diagnosis of malignant neoplasm of the pancreas. Documentation for the MSW initial assessment stated the visit was initiated on 02/22/2024 at 2:15pm and ended at 2:45pm. All areas of the assessment were left blank. During the IDT meeting, held on 2/27/24, the MSW documented "continuing to assess patients coping skills, disease progress, and safety. Ongoing support and education to patient's daughter and family related patients' disease progress and hospice care. Final arrangement will be completed." The record did not include documentation to indicate how the MSW assessed this information, and the plan of care was not updated during or following this meeting to include any psychosocial related problems, goals, or interventions. Clinical Record 5: The patient elected the hospice benefit on 01/20/2024 with a diagnosis of COPD. The plan of care contained orders for the social worker to conduct an initial assessment. The record did not contain evidence that the initial social worker assessment had been completed or documentation to support why the visit had not been made. During the IDT meetings, held on 1/31/24 and 02/14/2024, the MSW documented "continuing to assess patients coping skills, disease progress, and safety. Ongoing support and education to patient's conservator and SNF (skilled nursing facility) staff related patients' disease progress and hospice care. Final arrangement will be completed." The record did not include documentation to indicate how the MSW assessed this information, and the plan of care was not updated during or following these meetings to include any psychosocial related problems, goals, or interventions. Furthermore, for the IDT meeting conducted on 02/27/2024 the MSW documented "patient expired and all care plans closed" there were no psychosocial care plans that had been opened. The Clinical Operations Specialist who was interviewed on 03/26/2024 confirmed that these records did not have evidence that the psychosocial comprehensive assessments were completed within the five-day requirement.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by interview and personnel record review. In 5 of 7 (71%) personnel records reviewed, for individuals providing care, revealed the agency did not ensure adherence to the agency policies and procedures for performing and documenting the skills and competencies. Document 6: Employee Qualifications, Policy #205 (January 2017). Stated in part, "During the initial orientation period, hospice professional employees demonstrate competency based on orientation checklists developed for each type of hospice employees." "All employees providing patient care have an ongoing competency review as part of the annual performance evaluation." Personnel Record 3: RN case manager with a date of hire of 06/14/2017. Appointed as Director of Patient Care Services on 02/12/2024. The record did not include any completed skills competencies for 2022 or 2023; the last documented competency was dated 12/8/2021. Personnel Record 4: Licensed Vocational Nurse (LVN) and Clinical Operations Supervisor with a date of hire of 09/17/2019. The record did not include any completed skills competencies for 2023; the last documented competency was dated June 2022. Personnel Record 6: RN case manager with a date of hire of 03/21/2021. An initial skills competency was completed in December of 2021. The record did not include any other completed competencies. Personnel Record 7: Direct patient care and administrative volunteer with a date of hire of 01/23/2024. The record did not include any completed competencies. Personnel Record 8: Medical Social Worker with a date of hire of 11/02/2015. The record did not include any completed skills competency for 2023; the last completed competency was dated 02/09/2022. Personnel Record 4: An interview was conducted with the Clinical Operations Supervisor and the Human Resources (HR) Manager who confirmed that the competencies for the personnel records listed could not be located. The HR Manager stated, "I started keeping them (competency checklists) in a separate folder and since everything is boxed up for the move, I don't know which box they are in." The HR office was observed to have several boxes, all taped shut, which were kept in the locked office after hours. The agency was in the process of relocating.

It is required that the hospice EP (emergency preparedness) training program includes EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. Documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 2 (50%) volunteer personnel files reviewed, the organization failed to ensure ongoing education in emergency preparedness according to organizational policy. Staff policy titled, Staff Competency- Continuing Education Program, stated in part, "...Annually the clinical manager or designee develops an education plan for employee and volunteer education programs based on identified areas of need. In-service attendance records, program outlines, and other documentation are maintained by the clinical manager or designee. ...Hospice requires employees to complete the following education programs annually: Disaster Preparedness." Personnel Record 2: The volunteer's date of hire was 10/19/2020. Personnel file review with the DPCS and QAPI Coordinator revealed that there was no documentation of disaster preparedness training completed by the volunteer in 2022. The QAPI Coordinator spoke to the Volunteer Coordinator who confirmed that no ongoing education is documented or provided to volunteers after new hire orientation is complete and confirmed that this volunteer did not receive emergency preparedness training in 2022. The QAPI Coordinator stated during interview on 4/6/2023, that all other organization employees have received annual EP training through a learning management program and that all volunteers will be added to the learning management program training portal in order to be assigned all organization-required training effective today. Staff policy titled, Staff Competency- Continuing Education Program, states in part, "...Annually the clinical manager or designee develops an education plan for employee and volunteer education programs based on identified areas of need. In-service attendance records, program outlines, and other documentation are maintained by the clinical manager or designee. ...Hospice requires employees to complete the following education programs annually: ...Disaster Preparedness.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) initial benefit periods reviewed of patients receiving hospice care, it was revealed that the organization did not ensure that the hospice IDG completed a comprehensive assessment no later than five (5) calendar days after the election of hospice care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. Clinical Record 4: During the clinical record review performed with the DPCS and QAPI Coordinator on 4/6/23, it was revealed that the initial psychosocial and bereavement assessments were documented as completed on 3/16/23, 8 days after the benefit of election and start of care on 3/8/23. There was no documented order or reason for the delay found in the medical record. After a thorough review of the record, the DPCS confirmed during interview on 4/6/2023, that the initial comprehensive assessment was not completed within five (5) calendar days. This is a continuing prior required action.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 2 (50%) volunteer personnel files reviewed, it was revealed that the organization did not ensure ongoing education in infection control was provided to volunteer staff according to organizational policy. Organization policy titled, Staff Competency- Continuing Education Program, states in part, "...Annually the clinical manager or designee develops an education plan for employee and volunteer education programs based on identified areas of need. In-service attendance records, program outlines, and other documentation are maintained by the clinical manager or designee. ...Hospice requires employees to complete the following education programs annually: Exposure Control Plan; Tuberculosis; Handling and Disposal of contaminated materials. ..." Personnel Record 2: The volunteer's date of hire was 10/19/2020. Personnel file review with the DPCS and QAPI Coordinator revealed that there was no documentation of infection control training completed by the volunteer in 2022. The QAPI Coordinator spoke to the Volunteer Coordinator who confirmed that no ongoing education was documented or provided to volunteers after new hire orientation was complete and confirmed that this volunteer did not receive infection control training in 2022. The QAPI Coordinator stated in interview on 4/6/2023 that all other organization employees have received annual infection control training through a learning management program and that all volunteers will be added to the learning management program training portal in order to be assigned all organization-required training effective today. Organization policy titled, Staff Competency- Continuing Education Program, states in part, "...Annually the clinical manager or designee develops an education plan for employee and volunteer education programs based on identified areas of need. In-service attendance records, program outlines, and other documentation are maintained by the clinical manager or designee. ...Hospice requires employees to complete the following education programs annually: Exposure Control Plan; Tuberculosis; Handling and Disposal of contaminated materials. ..."

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interview. In 2 of 7 (29%) applicable records reviewed, there was evidence that the initial comprehensive assessment was not completed in five (5) calendar days. This evidence was confirmed by the QA/LVN during joint clinical record review on 5/5/2022. Record #55198, Start of Care 12/3/2021, Transfer to hospital 12/20/2021, Diagnosis Heart Disease: Review of the record revealed the initial Spiritual Counselor assessment was completed on 12/17/21, which was 14 days after the patient’s start of care, with no documented reason for delay. Record #56487, Start of Care 4/21/2022, Diagnosis Alzheimer’s: Review of the record revealed the initial SW and Bereavement assessments were completed 6 days after the patient’s start of care date with no documented reason for a delay.

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 reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and is evaluated annually. This standard was not met as evidenced by document review and interview. Review of the agency’s QAPI program documents revealed there was no documentation of the organization’s QAPI activities available for review for Quarters 3 and 4 of 2019, all 4 Quarters of 2020, and the first Quarter of 2022. During interview, the QA/LVN stated that the agency was unable to locate QAPI data for the 3rd and 4th Quarters of 2019 and 2020, and QAPI data for 2022 was “still being compiled” and was not presented for review prior to the end of the site visit review. 2021 QAPI data was provided for Quarters 1-4 and included evidence of quarterly QAPI committee meetings, which included attendance of members of the agency’s Governing Body who served as the agency’s QAPI Committee for 2021. The QA/LVN stated the agency leadership believed QAPI documents for 2019 and 2020 were in an off-site document storage facility, but stated there was “no time" to locate or retrieve this information prior to the end of the site visit review.

It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of: Adverse events. This standard was not met as evidenced by review of the agency’s QAPI program documents, which revealed there was no documentation available for review related to adverse patient events for Quarters 3 and 4 of 2019, and all 4 Quarters of 2020. Performance improvement activities initiated since 2021 included the tracking of adverse patient events, such as patient falls, but did not include documentary evidence of analysis of why the falls occurred or implementation of preventive action steps that included feedback from staff or education throughout the hospice.

It is required that the hospice maintains a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The infection control program includes a method for identifying infectious and communicable disease problems and a plan for implementing appropriate actions that are expected to result in improvement and disease prevention. This standard was not met as evidenced by document review and interview. Review of the agency’s QAPI program documents revealed there was no documentation available for review related to the organization’s infection control surveillance data for Quarters 3 and 4 of 2019, all 4 Quarters of 2020, and the first Quarter of 2022. The requested documentation included COVID-19 related employee illness and infections, patient related COVID illness infections, and actions taken when COVID was present to prevent its spread among staff, patients, family, and visitors. During interview, the QA/LVN stated that the agency was unable to locate QAPI data for the 3rd and 4th Quarters of 2019 and 2020, and QAPI data for 2022 was “still being compiled”. Review of 2021 QAPI data included monitoring and tracking of patient infections, such as UTIs and wounds, but there was no evidence of COVID-19 related infection surveillance data that had been reviewed and monitored as a part of its QAPI program in 2021 for patients or agency staff. The QA/LVN stated there was no COVID related infection data for patients or for staff that had been formally collected or tracked by the agency since the inception of the COVID-19 Public Health Emergency. The QA/LVN stated agency leadership believed infection surveillance, identification, prevention, control, and investigation of patient infectious and communicable diseases for 2019 and 2020 was in an off-site document storage facility, but stated there was “no time" to locate or retrieve this information prior to the end of the site visit review.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by a review of personnel records and interview. In 1 of 6 (17%) applicable personnel records reviewed of staff hired after the last renewal site visit dated 5/3/2019, there was no documented evidence of a completed skills competency assessment. Record #26133, Volunteer, Date of Hire 12/22/2021: There was no evidence of an initial skills competency assessment completed at the time of hire. The Volunteer Coordinator confirmed during interview on 5/5/2022 that an initial competency assessment of the volunteer was not completed prior to the volunteer furnishing direct care and services to patients and families. The Volunteer Coordinator stated that she was not aware of the competency requirement for volunteers.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40 and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 3 (33%) records of patients who received a transfer and/or live discharge, there was no evidence that the hospital received a copy of the discharge summary and/or patient record. Record #55198, Start of Care 12/3/2021, Transfer to hospital 12/20/2021, Diagnosis Heart Disease: During joint clinical record review, there was no evidence that the discharge summary and/or patient record was sent to the receiving hospital. During interview, the QA/LVN stated on 5/4/2022 that the hospice discharge summary and the patient’s record was not sent to the non-contracted hospital to which the patient was discharged.