Every finding on record at Socal Hospice Inc

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessments of Patients was met. 1. The hospice agency (HA) failed to conduct and document comprehensive assessment that reflect the patients current health status and identify patients need for hospice care and services related to hospice eligibility and management of terminal illness for 3 of 9 sampled patients. (Patients 1, 5 and 8) (Refer to L 521). 2. The HA failed to ensure all members of the interdisciplinary group (IDG) were consulted in the development of the plan of care within 5 days of start of care for 1 of 9 sampled patients (Patient 5). (L 523) 3. The HA failed to review all medication the patients were taking and update the medication profiles, had risk for medication errors and adverse drug reactions for one of 9 sampled patients (Patient 1). (Refer to L 530). 5. The HA failed to provide bereavement (the period of grief and mourning after a death) assessment on 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 for 4 of 9 sampled patients (Patients 2, 3, 6, and 9) (L 531) 5. The HA failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for one out of 9 sample patients (Patient 5) who did not meet the hospice criteria. (Refer to L 533). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure highest quality of care are provided to the patients assessed for eligibility to receive hospice care benefits.

b. A review of the Patient Profile Sheet, indicated Patient 5, was admitted to the hospice agency on 6/29/21, with a diagnosis of chronic obstructive pulmonary disease (COPD-a lung condition, causing difficulty breathing). During an interview on 6/16/22, at 2:05 p.m., the Director of Patient Care Services (DCPS) stated the agency used the LCD tool as part of the comprehensive assessment in determining if patient meets the criteria for hospice care. During an interview on 6/17/22, at 12:05 p.m., the DPCS stated the Certificate of Terminal Illness (CTI) is supposed to have a narrative stating patient has 6 months or less to live as well as documentation supporting the patient's criteria for hospice care. The DPCS stated Patient 5 did not have a narrative documented in the CTI. During an interview on 6/17/22, at 12:10 p.m., the DPCS did not know how the agency determined Patient 5 met hospice care criteria because the registered nurse (RN) who completed the admission Comprehensive Assessment did not document a LCD assessment. The DPCS stated, "Hmmm it does not show. It's supposed to be showing the pulmonary disease criteria for hospice, the LCD. The patient does not have one." A review of Patient 5's record titled, "Comprehensive Nursing Assessment", dated 6/29/21 did not have any documentation for section "Nature and Condition of Terminal Illness/LCD Eligibility Illness Trajectory and reason for hospice admission." A review of Patient 5's record titled "Physician's Certification for Hospice Benefit", for certification period 6/29/21-8/27/21, did not have a narrative to explain Patient's 5 clinical findings warranting hospice care. c. A review of the Patient Profile Sheet, indicated Patient 8, was admitted to the hospice agency on 7/6/20, with a diagnosis of hypertensive heart disease without failure (a long-term condition that develops over many years in people who have high blood pressure). During an interview on 6/16/22, at 2:05 p.m., the DPCS stated a registered nurse (RN) saw the patient within 24-48 hours from the start of care date (SOC) to perform the comprehensive assessment (an in depth-review of the physical, emotional, psychosocial, and spiritual needs of the patient, to establish the plan of care), to determine the needs of the patient. The DPCS stated the comprehensive assessment included an evaluation to determine if the patient needed durable medical equipment (DME), such as a walker, wheelchair, hospital bed, shower, and identifying other care needs in order for the patient to receive hospice care services and benefits. A review of the Hospice Agency's (HA) policy and procedures titled "Comprehensive Assessment", dated April 2020, indicated "Procedure: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information as relevant: ...P. Equipment presently in the home and potentially needed by the patient ..." Based on an interview, and record, the hospice agency staff failed to conduct and accurate comprehensive assessment that reflect the patients current health status and identify patients need for hospice care and services related to hospice eligibility and management of terminal illness for 3 of 9 sample selected patients. (Patients 1, 5 and 8). These deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six (6) months or less to Patients 1, 2, 5, and 6 , who were not clinically eligible to receive hospice care and services. Findings: a. A review of Patient 1's "Patient Profile Sheet" indicated Patient 1, was admitted to the hospice on 4/22/22, with a diagnosis of chronic obstructive pulmonary disease (COPD-a lung condition, causing difficulty breathing). A review of Patient 1's Comprehensive Nursing Assessment visit by the Registered Nurse (RN) dated 4/22/2022 indicated Patient 1 was awake, alert, oriented to person, place, and time, ambulates with the use of a cane and walker, requires oxygen at two liters per minutes (LPM) as needed (PRN). It also indicated Patient 1 had very limited mobility and his activity is chairfast. A review of Patient 1's Plan of Care (POC) dated 4/22/2022, indicated License Vocational Nurse (LVN 1) visit frequency was 1 time per week and Registered Nurse (RN 1) once per 2 weeks. A review of Patient 1's "Physician's Certification for Hospice Benefit," for the first 90-day period from 4/22/2022 to 7/20/2022, indicated Patient 1's terminal diagnosis was COPD. There was no documented evidence the hospice medical director or the hospice attending physician communicated with the primary physician to certify Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 1's Certification of Terminal Illness (CTI), indicated Physician 1 certified Patient 1 was ambulatory with assistance and was able to endure up to 3-5 steps, but needs maximum assistance in most activities. Physician 1 certified Patient 1 was eligible for hospice care and met LCD (Local Coverage Determination) guidelines. A review of Patient 1's Local Coverage of Determination (LCD), indicated Patient 1 was completely dependent on ambulation, toileting, transferring, and bathing. During an interview on 6/15/2022 at 1:55 p.m. with Patient 1 stated, he was not aware or been told by any physician that he had 6 months or less to live. Patient 1 stated that he had a Primary Physician since 2010, and seen him every 3 months for check up. Patient 1 further stated he has an appointment for blood draw and checkup tomorrow (6/16/2022). During an interview on 6/15/2022 at 1:55 p.m., with Patient 1, stated he walks around the block and sometimes 5 blocks (about 0.25 miles) up the street everyday using his walker. Patient 1 stated that on Mondays, Tuesdays, and Saturdays he collected recyclable materials using a shopping cart from his home to the park. During a telephone interview on 6/15/2022, at 3:35 p.m. with Patient 1's primary physician stated she did not refer Patient 1 to hospice. Patient 1's primary physician stated, "He has medical problems, but he is not dying ... For sure patient has more than one year to live. As far as I know, he doesn't have any terminal chronic conditions. His high blood pressure, diabetes, and cholesterol are well controlled. There is nothing warranting hospice care". During a telephone interview on 6/17/2022 at 1:45 p.m. with Physician 2 stated after Patient 1's Interdisciplinary Group (IDG) Meeting he needed to be discharged from hospice services because he did not meet criteria. Physician 2 also stated, "If the guidelines were being followed this patient should not have been admitted).

Based on interview and record review, the facility failed to ensure all members of the interdisciplinary group (IDG) were consulted in the development of the plan of care within 5 days of start of care for 1 of 9 sampled patients (Patient 5). This failure has the potential to result in the patient's hospice needs will not be identified necessary to develop the patient's plan of care. Findings: A review of the Patient Profile Sheet, indicated Patient 5, was admitted to the Hospice Agency (HA) on 6/29/21, with a diagnosis of chronic obstructive pulmonary disease (a lung condition, causing difficulty breathing). A review of Patient 5's clinical record indicated no documented evidence the IDG participated to develop the patient plan of care. During an interview on 6/17/22, at 11:45 a.m., the Director of Patient Care Services (DPCS), stated the plan of care was to be established on admission because it guides the staff on what the patient needs and what services the patients should be getting. The DPCS stated all members of the interdisciplinary team (IDG) were supposed to be involved in the development of the plan of care. During an interview on 6/17/22, at 12:12 p.m., the DPCS stated Patient 5 did not have a plan of care and wanted to know why there was not one present. The DPCS stated a plan of care was supposed to be developed for Patient 5 by the IDG. A review of the Hospice Agency's policy and procedures titled "The Plan of Care", dated November 2020, indicated "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."

Based on observation, interview, and record review the hospice agency failed to review all the medications the patient was taking and update the medication profile with the current medications for 1 of 9 sampled patients (Patient 1). This failure had the potential to result in placing the patient at risk of drug-to-drug interactions and harm by not knowing which medications the patient was taking. Findings: A review of Patient 1's "Patient Profile Sheet", indicated the patient was admitted to the hospice agency on 4/22/22, with a diagnosis of chronic obstructive pulmonary disease (COPD-a lung condition, causing difficulty breathing). A review of Patient 1's Plan of Care (POC) dated 4/22/2022, indicated Patient 1's License Vocational Nurse (LVN) visit frequency was 1 time per week, Registered Nurse (RN) 1 time per 2 weeks. A review of Patient 1's Comprehensive Nursing Assessment dated, 4/22/2022 indicated Patient 1 was awake, alert, oriented to place, time, and person. A concurrent observation and record review on 6/15/2022, at 1:40 p.m. with the Director of Patient Care Services (DPCS) of Patient 1's current medications was conducted during the home visit. The medication list was reconciled with the medications taken at home by the patient and revealed Patient 1 did not have two medications at home but listed on his medication profile and one medication taken at home but not listed in the medication profile as follows: 1. Ipratropium Bromide/Albuterol Sulfate 0.5-3 mg (milligrams)/3 ml (milliliters) solution for inhalation 1 nebule via handheld nebulizer every 4 hours as needed for shortness of breath/difficulty of breathing. 2. Olanzapine (treat mental disorders) 15 mg tablet 1 tablet oral daily with or without food. 3. Xarelto 10 mg (milligrams) by mouth everyday #30 filled 1/9/2022 Exp: 4/2024. During an interview on 6/15/2022 at 1:40 p.m., with the DPCS stated she was not aware Patient 1 was taking Xarelto medication. During an interview on 6/17/2022, at 11:45 a.m., with DPCS, stated that patients medication profile was produced on admission by asking the patient about the medications being taken. The DPCS stated that the visiting nurse needs to look at the medication profile and the patients medication bottles at every visit to keep the profile updated.

c. A review of the Patient Profile Sheet, indicated Patient 5, was admitted to hospice agency on 6/29/21, with a diagnosis of chronic obstructive pulmonary disease (COPD-a lung condition, causing difficulty breathing). A review of Patient 6's "Patient Profile Sheet", indicated the patient was admitted on 2/20/21, with a diagnosis of heart disease. There was no documented evidence bereavement services assessment was offered or conducted during the initial comprehensive assessment and incorporated in the plan of care. d. A review of the Patient Profile Sheet, indicated Patient 9, was admitted to the hospice agency on 4/26/21, with a diagnosis of hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure). There was no documented evidence bereavement services assessment was offered or conducted during the initial comprehensive assessment and incorporated in the plan of care. During an interview on 6/16/22, at 2:05 p.m., the DPCS stated the initial bereavement assessment should be done on admission because the agency needs to know how the patients feel about death and how they are coping about it; to assess the family also to see how they are coping, so the agency can offer counseling services if they are not coping well or need assistance. Based on interview and record review the hospice facility failed to provide bereavement assessment on 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 for 4 of 9 sampled patients (Patients 2, 3, 6, and 9). This failure had the potential for the patient' family and other individuals not being provided the bereavement needs and ablities to cope with the patient's passing or death. Findings: Reviews of electronic clinical records of Patient 2, Patient 5, Patient 6, and Patient 9 indicated there were no documented evidence of bereavement assessments were conducted by the hospice staffs. a. A review of the Patient Profile Sheet, indicated Patient 2, was admitted to the Hospice Agency on 3/12/21, with a diagnosis of rheumatic aortic stenosis with insufficiency (a heart condition). A review of Patient 2's Plan of Care (POC) indicated Skilled Nursing (SN) visit 1 time per week, Medical Social Worker (MSW) and Spiritual Counseling (SC) one time then PRN - then every recertification. Review of electronic clinical record of Patient 2, indicated no documented evidence of bereavement assessments were conducted by the hospice staffs. b. A review of Patient 3's "Profile Sheet", indicated patient was admitted to the Hospice Agency on 2/17/21, with a diagnosis of hypertensive heart disease without failure (a long-term condition that develops over many years in people who have high blood pressure). A review of Patient 3's POC indicated Skilled Nursing (SN) and Home Health Aide (HHA) visit 1 time per week, Medical Social Worker (MSW) one time then PRN - then every recertification. Review of electronic clinical record of Patient 3 indicated no documented evidence of bereavement assessments were conducted by the hospice staffs. During an interview on 6/17/2022, at 2:10 p.m., DPCS was not able to respond and provide documented evidence to indicate the Chaplain or Medical Social Worker, had performed bereavement assessments to Patients 2, and 3, and other responsible party for explanation of benefit for spiritual care services prior to or after death. A review of the Hospice Agency's undated policy and procedures titled "Bereavement Services", indicated "Procedure: 1. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care."

Based on interview and record review, the agency failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for one out of 9 sample selected patients (Patient 5). This deficient practice had the potential for the IDG not able to identify accurate information and document changes in the patient's condition or needs. Findings: A review of the Patient Profile Sheet, indicated Patient 5, was admitted to the hospice agency on 6/29/21, with a diagnosis of chronic obstructive pulmonary disease (a lung condition, causing difficulty breathing). A review of Patient 5's clinical record indicated Patient 5 had been on hospice for certification period of 6/29/21 to 7/15/21. A review of Patient 5's record titled "Comprehensive Nursing Assessment", dated 6/29/21, indicated there were no IDG signatures and no documented evidence of an evaluation of Patient 1's response to care, treatment, services provided and there was no progress toward desired outcome documented every 15 days. A review of the Hospice Agency's policy and procedures titled "The Plan of Care", dated November 2020, indicated, ...The plan of care will meet the documentation requirements of the physician-directed medical orders and the care process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessment performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days.

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Interdisciplinary group, care planning, and coordination of services, as follows: 1. Failed to ensure the interdisciplinary group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), in consultation with the patient's attending physician prepare a written plan of care for four of 11 sample patients, (Patient 1, Patient 2, Patient 6, Patient 9). (Refer to G537) 2. Failed to ensure a social worker and a chaplain were included in the interdisciplinary group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) for three of 11 sampled patients, (Patient 1, Patient 2, and Patient 6). (Refer to G541) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services.

Based on interview and record review, the hospice agency failed to designate an interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities to improve patient outcomes, healthcare processes and levels of satisfaction), in consultation with the patient's physician, in preparing the written plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for 2 of 9 samples patients (Patient 5 and Patient 8). This deficient practice has the potential risk to prevent the patients from reaching their care planning goals. Findings: a. A review of the Patient Profile Sheet, indicated Patient 5, was admitted to the Hospice Agency on 6/29/2021, with a diagnosis of chronic obstructive pulmonary disease (a lung condition, causing difficulty breathing). During an interview on 6/17/2022, at 11:45 a.m., the Director of Patient Care Services (DPCS), stated a plan of care was supposed to be established on admission because it guides the staff on what the needs of the patient are and what services they should be getting. The DPCS stated all members of the interdisciplinary team (IDG) were supposed to be involved in the development of the plan of care. The DPCS stated members of the IDG were the physician (doctor), registered nurse, chaplain, and medical social worker. During an interview on 6/17/2022, at 12:12 p.m., the DPCS stated Patient 5 did not have a plan of care and wanted to know why there was not one present. The DPCS stated a plan of care was supposed to be present for Patient 5. A review of the Hospice Agency's policy and procedures titled "The Plan of Care", dated November 2020, indicated "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." b. A review of the Patient Profile Sheet, indicated Patient 8, was admitted to the Hospice Agency (HA) on 7/6/2020, with a diagnosis of hypertensive heart disease without failure (a long-term condition that develops over many years in people who have high blood pressure). During an interview on 6/17/2022, at 12:15 p.m., the DPCS stated "It's our bible for the patient's care. It tells us what services to provide based on patient needs." When asked why it is important for patients to have a plan of care, the DPCS stated, it will tell us how hospice can help them." . A review of Patient 8's clinical record indicated Patient 8 was receiving hospice care from 7/6/2020 to 6/30/2021. A review of Patient 8's record titled "Plan of Care", for certification period 5/2/2021-6/30/2021, did not indicate interventions and goals in the plan. A review of the Hospice Agency's policy and procedures titled "The Plan of Care", dated November 2020, indicated, the plan of care will meet the documentation requirements of the physician-directed medical orders and the care process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessment performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days.

c. A review of the Patient Profile Sheet, indicated Patient 6, was admitted to the HA on 2/20/2021, with a diagnosis of heart disease (that refers to several types of heart condition). During an interview on 6/17/2022, at 12:22 p.m., the DPCS stated according to the plan of care (POC), Patient 6 was supposed to get skilled nursing visits once a week and 1 prn (as needed) visit, home aid (HA) 1 visit per week. During an interview on 6/17/2022, at 12:28 p.m., the DPCS stated the home health aide, HA was visiting Patient 6 two times a week, for certification period 5/2021-8/18/2021. When asked when the doctor provided the order, the DPCS stated "Hmm you are right, there is no order". During an interview on 6/17/2022, at 12:31 p.m.. the DPCS stated there were missed skilled nurse (SN) visits for the week of 7/11/2021 and 7/18/2021. The DPCS stated "you're right, there is no skilled nursing visits. I do not know why. I do not know if this was a missed visit or patient declined the visit because there is no note to explain what happened." A review of Patient 6 record titled, "Plan of Care", for certification period 5/21/2021-8/18/2021, indicated "Frequency of visits: HA: 1 per week ...SN: 1 per week + 1 prn visits ..." d. A review of the Patient Profile Sheet, indicated Patient 7, was admitted to the HA on 9/2/2020, with a diagnosis of alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 7 record titled, "Plan of Care", for certification period 6/29/2021-8/27/2021, indicated the frequency of visits: HA: 3 per week . Further review of the record did not indicate the 3 HA visits were made for the week of 5/16/2021 and 6/27/2021. There was no documentation to explain why the visits were missed. e. A review of the Patient Profile Sheet, indicated Patient 8, was admitted to the HA on 7/6/2020, with a diagnosis of hypertensive heart disease without failure (a long-term condition that develops over many years in people who have high blood pressure). A review of Patient 8's record titled "Plan of Care", for certification period 5/2/2021-6/30/2021, indicated, frequency of visits for RN (registered nurse) 1 per week + 2 prn (as needed) visits). Further review of the record did not indicate an RN visit was made for the week of 5/23/2021 and 5/30/2021. There was no documentation to explain why the visits were missed. Based on interview and record review, the hospice agency failed to ensure all care services furnished followed individualized plans of care established by the interdisciplinary team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) for five of 9 sampled patients, (Patient 1, Patient 2, Patient 6, Patient 7, and Patient 8). This failure resulted in patients not receiving the care/services from the home visits that can affect their highest practicable mental, physical and psychosocial well-being. Findings: a. A review of the Patient Profile Sheet, indicated Patient 1, was admitted to the Hospice Agency (HA) on 4/22/2022, with a diagnosis of chronic obstructive pulmonary disease (a lung condition, causing difficulty breathing). A review of Patient 1's Plan of Care (POC) dated 4/22/2022 indicated Patient 1's License Vocational Nurse visit frequency was 1 time per week, Registered Nurse (RN) 1 time per 2 weeks. During a concurrent interview and electronic medical record review on 6/15/2022, at 11:34 a.m., with Intake Coordinator (IC), of Patient 1's electronic medical record, IC stated Patient 1 had a nurse visit on 6/8/2022 but that the nurse had not documented in the medical record. IC stated that the nurses have 48 hours to submit documentation of visits. b. A review of the Patient Profile Sheet, indicated Patient 2, was admitted to the HA on 3/12/2021, with a diagnosis of rheumatic aortic stenosis with insufficiency (a heart condition). A review of Patient 2's Plan of Care (POC) indicated Patient 2 had an ordered Skilled Nursing (SN) visit 1 time per week. During a concurrent interview and record review on 6/17/2022 at 2:10 p.m. with the Director of Patient Care Services (DPCS), of Patient 2's electronic medical record, the DPCS stated that Patient 2 had missed visits the weeks of 3/21/2021 and 4/11/2021. During an interview on 6/17/2022 at 11:45 a.m. with Director of Patient Care Services (DPCS), the DPCS stated that patients Plan of Care (POC) includes everything that concerns patient services. The DPCS stated that the POC should have the visit frequency and the type of care the patient is receiving. A review of the Hospice Agency's policy and procedures titled "The Plan of Care", dated November 2020, indicated "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. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care process. It also indicated, "The plan of care will identify the patient's needs and services to meet those needs. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs. The written plan of care will contain, but will not be limited to, the following: DME and medical supplies necessary to meet patient needs, Frequency and type of services, anticipated discharge and bereavement care needs of the family." A review of facility's policy titled; "Missed Visits" revised April 2019, indicated missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.

Based on interview and record review the Hospice Agency (HA) failed to provide the comfort kit, (a prescribed set of medications that are kept in the patient's home in the event of an emergency) for 7 out of 9 sampled patients,(Patient 1, Patient 2, Patient 4, Patient 6, Patient 7, Patient 8, and Patient 9). This failure had the potential to result in patients not receiving their comfort medications timely, when needed during an emergency situation. Findings: a. A review of the Patient Profile Sheet, indicated Patient 6, was admitted to the Hospice Agency (HA) on 2/20/2021, with a diagnosis of heart disease (that refers to several types of heart conditions). During an interview on 6/16/2022, at 2:05 p.m., the director of patient care services (DPCS), stated a comfort kit (medications used to help with symptoms during the end of life) is supposed to be given to a patient when they are admitted to the hospice agency. The DPCS stated "the comfort kit is supposed to have: morphine in liquid form that is for pain; ativan, medicine for anxiety/restlessness or shortness of breath; levsin, to decrease secretions; atropine, to decrease secretions; dulcolax, for constipation; zofran, medicine for nausea, and tylenol, for fever or mild pain." The DPCS stated, "it was important for patients to have the comfort kit because anytime, when they show they are imminently dying, they have these medications to have them be comfortable through their passing." During an interview on 6/17/2022, at 12:32 p.m., the DPCS stated Patient 6 did not have a comfort kit and it was supposed to be given on admission. But due to cost effective measures, the hospice agency held comfort kit until they are imminently dying." A review of Patient 6's undated record titled, "Current Treatment/DME list", did not indicate the comfort kit listed. b. A review of the Patient Profile Sheet, indicated Patient 7, was admitted to the HA on 9/2/2020, with a diagnosis of alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 7's undated record titled, "Current Treatment/DME list", did not indicate the comfort kit listed. c. A review of the Patient Profile Sheet, indicated Patient 8, was admitted to the Hospice Agency (HA) on 7/6/2020, with a diagnosis of hypertensive heart disease without failure (a long-term condition that develops over many years in people who have high blood pressure). A review of Patient 8's undated record titled, "Current Treatment/DME list", did not indicate the comfort kit listed. d. A review of the Patient Profile Sheet, indicated Patient 9, was admitted to the HA on 4/26/2021, with a diagnosis of hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure). A review of Patient 9's undated record titled, "Current Treatment/DME list", did not indicate the comfort kit listed. A review of the Hospice Agency's policy and procedures titled, "The Plan of Care", dated November 2020, indicated, the plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief." e. A review of the Patient Profile, indicated Patient 1, was admitted to the HA on 4/22/2022, with a diagnosis of chronic obstructive pulmonary disease (a lung condition, causing difficulty breathing). A review of Patient 1's Medication Profile did not indicate the comfort kit. A review of the Patient Profile, indicated Patient 2, was admitted to the HA on 3/12/2021, with a diagnosis of rheumatic aortic stenosis with insufficiency (a heart condition). f. A review of Patient 2's Medication Profile did not indicate the comfort kit.. A review of the Patient Profile Sheet, indicated Patient 4, was admitted to the HA on 2/920/21, with a diagnosis of atherosclerotic heart disease (a type of heart condition). g. A review of Patient 4's Medication Profile did not indicate the comfort kit. During a concurrent interview and electronic record review on 6/17/2022 at 2:10 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that there were no Comfort Kits ordered for these patients. DPCS also stated that the HA did not have a policy for Comfort Kits

Based on interview and record review the hospice agency (HA) failed to ensure that the Condition of Participation for Quality Assessment and Performance Improvement (QAPI, the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI) were met as follows: 1. Maintain and provide evidence of an ongoing hospice-wide data-driven quality assessment and performance improvement (QAPI) program and its implementation. (Refer to L560) 2. Ensure presence of the hospice's governing body (responsible for developing and reviewing the overall mission and strategy, guides the long-term goals and policies by making strategic plans and decisions and documentation and is responsible in ensuring an ongoing program for quality improvement and patient safety) is defined, implemented, and maintained, and is evaluated annually. (Refer to L574) The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of a quality health care in a safe environment. .

Based on interview and record review, the hospice agency (HA) failed provide evidence that quality assessment and performance improvement (QAPI, the coordinated application of two mutually-reinforcing aspects of a quality management system: quality assurance (QA) and performance improvement (PI), was developed by the hospice indicating continuous, and periodic collection and assessment of data to identify whether a problem exists in the hospice agency. This deficient practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care. Findings: During an interview on 6/17/2022, at 2:58 p.m., the Director of Patient Care Services (DPCS) stated the last time the agency had a QAPI program was in March 2021. The DPCS did not provide a reason why the QAPI program had not continued. The DPCS stated despite their low census, the agency should have continued with the QAPI program. A review of the HA's policy and procedure titled, "Responsibilities of QAPI Committee", dated April 2019, indicated "Department managers and supervisors are responsible for providing leadership to ensure the communication and coordination of QAPI activities."

Based on interview and record review, the governing body (responsible for developing and reviewing the overall mission and strategy, guides the long-term goals and policies by making strategic plans and decisions and documentation and is responsible in ensuring an ongoing program for quality improvement and patient safety) failed to ensure full responsibility for the operation of the hospice program for quality improvement and patient safety. This deficient practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care. Findings: During an interview on 6/17/2022, at 2:58 p.m., the Director of Patient Care Services (DPCS) stated since she left the hospice agency for a personal leave of absence in June 2021, no one has looked at the QAPI program. The DPCS stated the QAPI members included the DPCS, administrator and nurses. A review of the HA's policy and procedure titled, "Leadership", dated April 2019, indicated, the Governing Body is ultimately responsible for the QAPI Plan and for ensuring: that the QAPI Plan is ongoing, implemented and maintained.

Based on observation, interview, and record review, the hospice agency (HA) failed to implement its COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) policy and procedures by failing to ensure the visitors were being screened for signs and symptoms of COVID-19 including the temperature check. This deficient practice resulted in placing the patients, staff, and visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. Findings: During an observation on 6/14/22, at 3:00 p.m., upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check. During an observation on 6/15/22, at 09:00 a.m., upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check. During an observation on 6/16/22, at 09:00 a.m., upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check. During an observation on 6/17/22, at 10:00 a.m., upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check. During an interview on 6/17/22, at 2:54 p.m., the Director of Patient Care Services (DPCS) stated, "No, we did not screen you for COVID symptoms. We have not been doing that. No, we don't screen our employees. There is no log of temperature checks". The DPCS stated there is a risk of transmitting the virus to patients and staff by not screening the employees and visitors. A review of facility's policy titled, "Corporate Compliance Plan" revised April 2019 indicated hospice agency has established this plan to ensure that quality patient care is provided in a manner that fully complies with all applicable state and federal laws and regulations.

c. A review of the Patient Profile Sheet, indicated Patient 5, was admitted to the Hospice Agency on 6/29/21, with a diagnosis of chronic obstructive pulmonary disease (a lung condition, causing difficulty breathing). During an interview on 6/16/22, at 2:05 p.m., the director of patient care services (DPCS) stated a social worker must see all the patients on admission. The DPCS stated if the registered nurse says patient declined the service, on initial assessment, the social worker still must call the patient to explain the services. A review of Patient 5's record for certification period 6/29/21-8/27/21, did not indicate the patient received a social worker assessment or evaluation. d. A review of the Patient Profile Sheet, indicated Patient 6, was admitted to the Hospice Agency on 2/20/21, with a diagnosis of heart disease. A review of Patient 6's record for re-certification period 5/21/21-8/218/21, did not indicate the patient received a social worker re-assessment or evaluation. Based on interview and record review, the hospice failed to provide all core services including medical social services for four of 9 sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6). This deficient practice placed the patient and family member at risk for not being fully evaluated and not receiving the support for their emotional and grieving needs. Findings: a. A review of the Patient Profile Sheet, indicated Patient 1, was admitted to the hospice agency on 4/22/22, with a diagnosis of chronic obstructive pulmonary disease (a lung condition, causing difficulty breathing). A review of Patient 1's Plan of Care (POC) dated 4/22/2022 indicated Patient 1's License Vocational Nurse visit frequency was 1 time per week, Registered Nurse (RN) 1 time per 2 weeks. During an interview on 6/15/2022, at 1:55 p.m., with Patient 1, Patient 1 stated that he was not aware that the Hospice Agency offered volunteer, social worker, or home health aide services. During an observation on 6/15/2022, at 2:30 p.m., of the Director of Patient Care Services (DPCS) and Patient 1, Patient 1 was requesting to the DPCS, at home assistance for his laundry and to pick up a little. DPCS stated to Patient 1, "I see you don't have a social worker or health aide. I suggest you see our social worker and she will assist you with what you are asking for. They can help you at home, assist you in shower, activities. We do have that". b. A review of the Patient Profile Sheet, indicated Patient 2, was admitted to the Hospice Agency (HA) on 3/12/21, with a diagnosis of rheumatic aortic stenosis with insufficiency (a heart condition). A review of Patient 2's Plan of Care (POC) indicated Patient 2 had ordered Skilled Nursing (SN) visit 1 time per week, Medical Social Worker (MSW) and Spiritual Counseling (SC) one time then PRN - then every recertification. During a concurrent interview and record review on 6/17/2022, at 2:10 p.m., with Director of Patient Care Services (DPCS) of Patient 2's electronic medical record, DPCS was not able to provide the documented evidence the Medical Social Worker (MSW) had attempted to contact the patient/caregiver for explanation of benefits of social services. A review of the Hospice Agency's (HA) policy and procedures titled "Psychosocial Assessment", dated April 2020, indicated "An-depth psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse."

Based on interview and record review the facility failed to provide facility to 3 of 12 employees files reviewed (CHHA 1, IC, and MSW). This failure had the potential to result in patients being taken cared for by an unqualified hospice agency personnel. Findings: During a record review of personnel files, the personnel files indicated Certified Home Health Aide 1 (CHHA 1), Intake Coordinator (IC), and Medical Social Worker (MSW) did not have documented evidence these employees received orientation when hired. During and interview on 6/16/2022, at 2 p.m., with Director of Patient Care Services (DPCS), DPCS stated that none of the three personnel files contained proof that they had been oriented. DPCS stated, "I don't know if they did or didn't. I can't find the forms in their files". A review of facility's policy titled, "Personnel Record Content" revised November 2020 indicated the content of the personnel files for regular, full-, or part-time personnel will include: 1. New Hire: F- Orientation checklist.

Based on interview and record review the Hospice Agency failed to provide two of two personnel files to be reviewed (Administrator (ADM) and a Registered Nurse 1 (RN 1). This failure resulted in not knowing if these two staff members are qualified to perform their job descriptions, which places patients at risk for being taken care of an unqualified personnel. Findings: During an interview on 6/16/2022 at 1:30 p.m. with Director of Patient Care Services (DPCS), DPCS stated that they were unable to locate the personnel files of the ADM and RN 1. A review of facility's policy titled, "Personnel Record Content" revised November 2020 indicated Hospice Agency (HA) will maintain accurate and complete personnel files on all direct staff and independent contractors. Upon request, hospice will provide personnel with a copy of all confidential information being placed in the file.