Every finding on record at Soft Touch Hospice, Inc.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 4 of 11 (36%) clinical records reviewed revealed the hospice did not ensure that skilled nursing services performed matched the frequency of nursing visits included in the patient's plan of care. Record #4 was reviewed and identified the patient elected hospice care on 12/14/21. The Interdisciplinary Group (IDG) plan of care (POC) dated 4/13/22, documented SN visits were to be performed one time each week and one time as needed for pain management and comfort measures. The record was missing SN visits documented as completed for the weeks including 6/12/22 and 6/26/22. In addition, the record was did not include documented missed visits and communication with the physician to change the SN visit frequency. Record #2 was reviewed and identified the patient elected hospice care on 6/2/22. The IDG POC dated 6/2/22, documented SN visits were to be performed one time each week and one time as needed for pain management and comfort measures. The record was missing SN visits documented as completed for the weeks including 6/5/22, 6/13/22, and 6/20/22. In addition, the record was did not include documented missed visits and communication with the physician to change the SN visit frequency. Record #8 was reviewed and identified the patient elected hospice care on 1/12/22. The IDG POC dated 1/12/22, documented SN visits were to be performed one time each week and one time as needed for pain management and comfort measures. The record was missing a SN visit documented as completed for the week of 5/8/22. In addition, the record was did not include a documented missed visit and communication with the physician to change the SN visit frequency. Record #3 was reviewed and identified the patient elected hospice care on 12/29/21. The IDG POC dated 12/29/21, documented SN visits were to be performed one time each week and one time as needed for pain management and comfort measures. The record was missing SN visits documented as completed for the weeks including 4/24/22, 5/1/22, and 5/8/22. In addition, the record was did not include documented missed visits and communication with the physician to change the SN visit frequency. The agency's policy #9-017 "The Plan of Care (revised 11/2020), stated in part, "The care provided to the patient must be in accordance with the POC." The Director of Patient Care Services and Licensed Vocational Quality Nurse were interviewed and confirmed the SN visit frequencies were not followed.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 3 of 11 (27%) clinical records reviewed revealed the hospice failed to ensure that the patient's written plan of care reflects goal(s) and identifies planned intervention(s) based on problems identified in the initial and updated comprehensive assessments. Record #2: The Certificate of Terminal Illness (CTI) dated 6/2/22 for the certification period dated 6/2/22 through 8/30/22, documented that the patient was using, "Oxygen 2-4L/min per nasal cannula at night." The Interdisciplinary Group (IDG) Plan of Care (POC) dated 6/2/22 was missing goals and interventions for Oxygen. Record #0: The CTI dated 6/30/22 for the certification period dated 6/30/22 through 8/28/22 documented the patient was diagnosed with COVID 19. The IDG POC dated 6/30/22 was missing goals and interventions addressing the diagnosed COVID-19. Record #9: The CTI dated 6/6/22 for the certification period dated 6/5/22 through 8/3/22 documented the patient was a fall risk. The IDG POC dated 6/5/22 was missing goals and interventions for the patient's identified risk of falls. The agency policy #9-017 "The Plan of Care" (revised 11/2020), "stated in part, "A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program...The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments...This plan will focus on identified problems, goals, and interventions." The Director of Patient Care Services and the Licensed Vocational Quality Nurse on 7/22/22 during an interview, reviewed the records and confirmed the goals and interventions were missing from the plans of care.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 1 of 11 (9%) clinical records reviewed revealed the hospice failed to ensure that the Interdisciplinary Group (IDG) reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days.. Record #3 was reviewed and revealed the patient elected hospice care on 12/29/21. The IDG meetings documented as completed following the week of 4/17/22, included the IDG meetings dated 4/20/22 and 5/4/22. The record was missing documented evidence of an IDG meeting and plan of care occurring as of 5/25/2022 when the patient was transferred to another hospice. The agency's policy #9-017 "The Plan of Care" (revised 11/2020), stated in part, "The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days." The Director of Patient Care Services and Licensed Vocational Quality Nurse were interviewed and confirmed there was not an IDG meeting on 5/18/22.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and. the frequency of service delivery. This standard was not met as evidenced by document reviews and interviews. The hospice failed to ensure that a post bereavement program is available to the family and other individuals up to one (1) year following the death of the patient. During the phone interview on 7/22/22 at 8 am, the Bereavement Coordinator (BC) verbalized pieces and parts of the agency's post death bereavement program. The BC was unsure where to find components available in the electronic medical record for the post death bereavement program, such as the bereavement plans of care for low, moderate and high risks, and letters to be personalized and mailed to the bereaved. In addition, the BC did not maintain a tracking system to post the death of the patient, bereaved name, intervention target dates and the frequency of service delivery. The agency's policy #1-021 "Bereavement Assessment" (revised 11/2020), stated in part, "The agency will provide bereavement services for up to one (1) year after the patient's death to surviving family/caregiver members." The Director of Patient Care Services and Licensed Vocational Quality Nurse were interviewed and confirmed the agency's post death bereavement program needs to be a written formal process. This agency lacks a documented post death bereavement program.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group (IDG) and is included in the plan of care. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 1 of 1 (100%) clinical records reviewed for patients that accepted Hospice Aide services revealed the hospice failed to ensure that the Aide provided services ordered by the interdisciplinary group and included in the plan of care.. Record #8 was reviewed and identified the patient elected hospice care on 1/12/22. The patient declined Aide services at the time of admission. The physician's order dated 5/1/22, documented, "Hospice Aide 2x/week." The record revealed a visit note completed by the Aide dated 6/1/22. There were no further visit notes completed by the Aide. In addition, the record was missing communication notes and changes in the physician's order to support the missing Aide visits. The agency's policy #9-017 "The Plan of Care" (revised 11/2020), stated in part, "The care provided to the patient must be in accordance with the plan of care." The Director of Patient Care Services and Licensed Vocational Quality Nurse during an interview confirmed the hospice aide did not provide services ordered by the IDG.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 1 (100%) clinical records reviewed for patients that were transferred/discharged, revealed the hospice failed to ensure that the receiving facility received a copy of the hospice discharge summary. Record #3 was reviewed and identified that the patient elected hospice care on 12/29/21. The patient was transferred to another hospice on 5/25/22. The record lacked evidence that the transfer/discharge summary was sent to the receiving hospice. The agency policy" #1-022 "Transfer Information" (revised:11/2020), stated in part, "Procedure... Completed transfer summaries will be given to a clinical records clerk who will send a copy to the receiving organization within 72 hours of transfer and file the original in the clinical record. The Director of Patient Care Services and Licensed Vocational Quality Nurse were interviewed and confirmed the discharge summary was not sent to the receiving hospice.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 2 of 2 (100%) clinical records reviewed of patients that revoked hospice services revealed the hospice failed to forward the patient's attending physician a copy of the hospice discharge summary. Record #2 was reviewed and identified that the patient elected hospice care on 6/2/22. On 6/29/22, the patient caregiver revoked hospice services to seek aggressive treatment for the patient. The record was missing evidence that the discharge summary was forwarded to the patient's attending physician. Record #9 was reviewed and identified that the patient elected hospice care on 1/6/22. The patient revoked hospice services on 7/15/22 to pursue aggressive treatment. The record was missing evidence that the discharge summary was forwarded to the patient's attending physician. The agency's policy #1-024 "Revocation of Hospice Benefit" (revised 11/2020), stated in part, "Procedure....The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician." The Director of Patient Care Services and Licensed Vocational Quality Nurse during an interview, confirmed the discharge summaries were not forwarded to the patient's attending physician.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address informing local and state emergency officials of any on-duty employees and patients that the hospice is unable to contact. This standard was not met as evidenced by review of documents and interview. The hospice did not ensure the emergency preparedness (EP) policies and procedures addressed informing local and state emergency officials of any on-duty employees and patients that the hospice is unable to contact. During interview on 4/21/22, the Office Manager and Alternate Administrator could not locate the missing emergency preparedness policies and procedures which addressed informing local and state emergency officials of any on-duty employees and patients that the hospice is unable to contact.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address informing local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency based on the patient’s medical or psychiatric condition, or home environment. This standard was not met as evidenced by review of documents and interview. The hospice did not ensure the emergency preparedness (EP) policies and procedures addressed informing local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency based on the patient’s medical or psychiatric condition, or home environment. The emergency plan documents did not identify which local and state emergency officials would be informed for patients in need of evacuation. During interview on 4/21/22, the Office Manager and Alternate Administrator could not locate the missing emergency preparedness policies and procedures which addressed informing local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency.

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 review of clinical records and interview. 2 of 11 (18%) clinical records reviewed revealed the Hospice did not ensure an initial comprehensive assessment was completed no later than five (5) days after the election of hospice care. Record #98998 was reviewed and identified the patient elected hospice care on 12/14/22. The clinical record did not contain an initial psychosocial assessment within five (5) calendar days after the election of hospice care. The initial psychosocial assessment was documented on 12/17/21. Record #97010 was reviewed and identified the patient elected hospice care on 12/14/22. The clinical record did not contain an initial spiritual assessment. Review of the clinical record revealed phone contact was attempted by the spiritual counselor on 12/16/21. The note read "phone call for attempted visit, will try to reach patient for initial assessment". There was no documented follow up to complete the initial spiritual assessment. During interview on 4/20/22 and 4/21/22, the QA Coordinator stated he could not locate the missing social worker and spiritual counselor initial assessments. The Alternate Administrator confirmed the missing initial assessments.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by interview and clinical record review. 8 of 11 (73%) clinical records reviewed revealed the hospice did not ensure an update of the comprehensive assessment was completed by the hospice Interdisciplinary Group no less frequently than every 21 days. During the public health emergency (PHE), the timeframe for updating the comprehensive assessment is extended from 15 days to 21 days. Record #48595 was reviewed and identified missing updates of the comprehensive assessment for timeframe 2/10/22 through 3/22/22. The "update of the comprehensive assessment" sections for "SN" on the "POC/IDG Review" forms only included "continue with plan of care" and did not include a nursing update of the comprehensive assessment Record #56868 was reviewed and identified missing updates of the comprehensive assessment for timeframe 2/10/22 through 3/22/22. The "update of the comprehensive assessment" sections for "SN" on the "POC/IDG Review" forms only included "continue with plan of care" and did not include a nursing update of the comprehensive assessment Record #29439 was reviewed and identified missing updates of the comprehensive assessment for timeframes 2/10/22 through 3/22/22 and 3/24/22 through 4/20/22. . The "update of the comprehensive assessment" sections for "SN" on the "POC/IDG Review" forms only included "continue with plan of care" and did not include a nursing update of the comprehensive assessment Record #84493 was reviewed and identified missing updates of the comprehensive assessment for timeframe 2/10/22 through 3/22/22. The "update of the comprehensive assessment" sections for "SN" on the "POC/IDG Review" forms only included "continue with plan of care" and did not include a nursing update of the comprehensive assessment Record #97010 was reviewed and identified missing updates of the comprehensive assessment for timeframe 3/24/22 through 4/20/22. The "update of the comprehensive assessment" sections for "SN" on the "POC/IDG Review" forms only included "continue with plan of care" and did not include a nursing update of the comprehensive assessment Record #37418 was reviewed and identified missing updates of the comprehensive assessment for timeframe 1/13/22 through 2/8/22. The "update of the comprehensive assessment" sections for "SN" on the "POC/IDG Review" forms only included "continue with plan of care" and did not include a nursing update of the comprehensive assessment Record #40689 was reviewed and identified patient revoked hospice services on 12/13/21. There were no nursing, spiritual and spiritual updates of the comprehensive assessment for timeframe 11/4/21 through 12/13/21. Review of the clinical record revealed missing "POC/IDG Review" forms for timeframe 11/4/21 through 12/13/22 that are to be implemented for documenting the interdisciplinary update of the comprehensive assessment. Record #98998 was reviewed and identified missing updates of the comprehensive assessment for timeframe 2/10/22 through 3/22/22. The "update of the comprehensive assessment" sections for "SN" on the "POC/IDG Review" forms only included "continue with plan of care" and did not include a nursing update of the comprehensive assessment. During interview on 4/21/22, the Alternate Administrator and QA Coordinator confirmed the missing interdisciplinary nursing, psychosocial and/or spiritual updates of the comprehensive assessment on the "POC/IDG Review" forms.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG members provide the care and services offered by the organization. The IDG, in its entirety, supervises the care and services provided to the patient and family. This CONDITION was not met as evidenced by clinical record review, document review and interview. The hospice failed to ensure care and services furnished to patients and their families followed an individualized written plan of care established by the hospice IDG [HCPC.19.I/L543]; that written plans of care for each patient reflected patient and family goals and interventions based on the problems identified in the initial and updated comprehensive assessments [HCPC.21.I/L545] and the IDG did not review, revise and document the individualized plan as frequently as the patient’s condition required, but no less frequently than every 15 calendar days [HCPC.22.I/L552]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality patient care in a safe environment. This is a CMS CONDITION LEVEL deficiency.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by interview and clinical record review. 6 of 11 (55%) clinical records revealed the hospice did not ensure care and services followed the visit frequencies in the plan of care established by the hospice IDG. Record #83447 was reviewed and the "POC IDG Review" 3/9/22, 3/23/22, 4/5/22 and 4/20/22 included the nursing visit frequency of one time a week. The clinical record was missing one nursing visit the weeks of 3/27/22, 4/10/22 and 4/17/22. The last nursing visit was documented on 4/5/22, the "POC IDG Review" 4/6/22 included "patient revoked hospice on 4/5/22" and there was no patient signed revocation statement or order to discharge due to revocation. The patient was still listed on the active patient census as of 4/21/22. During interview on 4/21/22, the Office Manager stated "The patient is still on service and I just called the family and confirmed that the patient did not revoke and is still on hospice service". The Hospice RN who was assigned to visit the patient was not available for interview. During interview 4/21/22, the alternate administrator and QA Coordinator confirmed missing nursing visit notes since 4/5/22. Record #37418 was reviewed and the plan of care included the nursing visit frequency of one time a week. The clinical record was missing one nursing visit the week of 3/6/22, 3/20/22 and 4/3/22. Record #48595 was reviewed and the plan of care included the nursing visit frequency of one time a week. The clinical record was missing one nursing visit the week of 3/27/22. Record #56868 was reviewed and the plan of care included the nursing visit frequency of one time a week. The clinical record was missing one nursing visit the week of 3/20/22. Record #29439 was reviewed and the plan of care included the nursing visit frequency of one time a week. The clinical record was missing one nursing visit the week of 3/9/22. Record #84493 was reviewed and the plan of care included the nursing visit frequency of one time a week. The clinical record was missing one nursing visit the week of 3/27/22. Additionally, 5 of 11 (45%) clinical records reviewed revealed the hospice did not ensure spiritual counselor visits followed the visit frequencies in the plan of care established by the hospice IDG. Record #31552 was reviewed and the "POC IDG" plan of care dated 1/26/22 included the spiritual counselor visit frequency of "SC to provide monthly support". The clinical record was missing the monthly spiritual counselor visit for February 2022. Record #40689 was reviewed and the "POC IDG" plan of care dated 11/3/21 included the spiritual counselor visit frequency of monthly. The clinical record was missing the monthly spiritual counselor visit for November 2021. Record #33288 was reviewed and the "POC IDG" plan of care dated 3/9/22, 3/23/22 and 4/6/22 included the spiritual counselor visit frequency of one time a monthly. The clinical record was missing the monthly spiritual counselor visit for March 2022. Record #98998 was reviewed and the "POC IDG" plan of care dated 3/9/22, 3/23/22 and 4/6/22 included the spiritual counselor visit frequency of "initial assessment, recertification and as needed". The clinical record was missing the spiritual counselor visit for the 4/13/22 recertification. Record #84493 was reviewed and the spiritual counselor visit note 2/21/22 read, "will provide monthly spiritual support". The clinical record did not include monthly spiritual support for March 2022. Additionally, 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure social worker visits followed the visit frequencies in the plan of care established by the hospice IDG. Record #33288 was reviewed and the "POC IDG" plan of care dated 3/9/22, 3/23/22 and 4/6/22 included the social worker visit frequency of one time a monthly. The clinical record was missing the monthly social worker visit for March 2022. Record #98998 was reviewed and the "POC IDG" plan of care dated 3/9/22, 3/23/22 and 4/6/22 included the social worker visit frequency of "initial assessment, recertification and as needed". The clinical record was missing the social worker visit for the 4/13/22 recertification. Additionally, 1 of 1 (100%) clinical records reviewed revealed the hospice did not ensure volunteer visits followed the visit frequencies in the plan of care established by the hospice IDG. Record #40689 was reviewed and revealed the patient elected hospice care 9/18/21 and revoked hospice services 12/13/21. The "POC IDG Review" 11/3/21 included "volunteer one time a week to provide respite break for family, run errands, provide transportation, comfort and support, and companionship". The clinical record was missing one volunteer visit the weeks of 11/3/21, 11/7/21, 11/14/21, 11/28/21 and 12/5/21. During interview on 4/21/22, the Office Manager who is designated by the administrator to coordinate the visit schedule stated she was not aware that the patient had volunteer visits included in the plan of care. During clinical record review and interview on 4/21/22, the alternate administrator and QA Coordinator stated they could not locate the missing nursing, social worker, spiritual counselor and volunteer visit notes. During interview on 4/21/22, the alternate administrator/RN confirmed the visit frequencies that are included in the "POC IDG Review" forms and acknowledged that training needed to be done to educate staff on updating visit frequencies. During interview on 4/21/22, the Office Manager and HR Manager confirmed that the hospice was in the process of hiring another RN. During phone interview 4/21/22, the Director of Patient Care Services (DPCS) stated "I resigned last week" then called back to state "I will continue working with this hospice as the DPCS".

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical records and interview. 11 of 11 (100%) clinical records of patients receiving nursing, social worker and/or spiritual counselor services, the hospice did not ensure patients’ plans of care reflected patient/family goals and interventions based on problems identified in the comprehensive assessments. Record #31552: The initial nursing assessment 1/12/22 included "malignant cancer of the stomach, constipation, forgetfulness, decline in functional and cognitive functions, appetite poor, incontinent, redness of coccyx, near fall 2 days ago and daughter reports patient has fallen several times." The plan of care contained no interventions to address constipation. During home visit interview 4/22/22, the alert and oriented patient stated "I had surgery 8 years ago and I see the doctor yearly and was told I no longer have cancer of the stomach and I don't have pain now but if I do, I will take Tylenol" and "I do have numbness and discomfort of the lower legs and arms and would like some balm to rub on these areas". This was reported to the hospice. The initial spiritual counselor assessment 1/14/22 included "will provide monthly spiritual support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the spiritual assessment. The initial psychosocial assessment 1/14/22 included, "social worker will follow up with patient and family as needed for emotional and psychosocial support". The plan of care with the social worker goals and interventions was not established until 3/12/22. Record #48595: The initial nursing assessment 12/29/21 included "decline in functional and cognitive functions, sleep apnea, shortness of breath with exertion, edema, umbilical hernia and intermittent pain attacks". The clinical record did not contain a plan of care which identified goals or planned interventions based on these problems identified in the initial nursing assessment. Pain medication was ordered on 1/6/22. The spiritual counselor recertification assessment visit 3/25/22 included "provided spiritual support". The clinical record did not contain a plan of care which identified planned interventions or goals based on the spiritual assessment. The social worker recertification assessment visit 3/28/22 included, "social worker will follow to assist patient and family as needed for emotional and psychosocial support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the psychosocial identified needs. Record #56868: The initial nursing assessment 10/12/21 included "recent fall, contracted arm and tremors". The clinical record did not contain a plan of care which identified goals or planned interventions based on these problems identified in the initial nursing assessment. The recertification spiritual assessment 3/31/22 included "will continue to provide spiritual support per plan of care". The clinical record did not contain a plan of care for the identified spiritual needs. The initial psychosocial assessment 10/16/21 included, "will continue to follow up POLST, advanced directives, final arrangements mortuary". The clinical record did not contain a plan of care for the identified psychosocial needs. Record #29439: The initial nursing assessment 1/10/22 included "decline in functional and cognitive functions, forgetfulness and continuous pan". The clinical record did not contain a plan of care which identified goals or planned interventions based on these problems identified in the initial nursing assessment. Pain medication was ordered on 1/6/22. The initial spiritual assessment 1/14/22 included "will continue to provide spiritual support" and the clinical record revealed the patient refused spiritual counselor services 3/9/22. The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial spiritual assessment until services were declined 3/9/22. The initial psychosocial assessment 1/14/22 included, "feels sad at times, denies suicidal thoughts or plans, will follow up as needed to assist with community resources, education on disease process and to provide emotional and psychosocial support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial psychosocial assessment. Record #98998: The initial nursing assessment 12/14/21 included the identified problems of "comfort and pain management, and incontinent". The clinical record did not contain a plan of care which identified goals or planned interventions based on these problems identified in the initial nursing assessment. Pain medication was ordered on 1/6/22. The initial spiritual assessment 12/17/21 included "will continue to provide monthly spiritual support follow up". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial spiritual assessment. The initial psychosocial assessment 12/27/21 included, "will follow up as needed to assist with community resources, education on disease process and to provide emotional and psychosocial support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial psychosocial assessment. Record #84493: The initial nursing assessment 11/30/21 included the identified problems of "comfort and pain management, urinary retention, forgetfulness and decline in functional and cognitive functions". The clinical record did not contain a plan of care which identified goals or planned interventions based on these problems identified in the initial nursing assessment. Pain medication was ordered on 11/30/21. The recertification social worker reassessment 2/27/22 included, "will follow up as needed to assist with community resources, education on disease process and to provide emotional and psychosocial support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the social worker assessment. The plan of care did contain problem, goals and interventions based on the initial spiritual assessment 11/30/21. Record #83447: The initial nursing assessment 1/6/22 included the identified problems of "comfort and pain management, and incontinent". The clinical record did not contain a plan of care for pain and incontinence which identified goals or planned interventions based on these problems identified in the initial nursing assessment, other than ordered pain medication 1/6/22. The plan of care did include a cardiac problem, goal and intervention dated 1/6/22 and updated 3/2/22. The initial spiritual and recertification assessments included "will continue to provide spiritual support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial spiritual and recertification assessments. The initial psychosocial assessment and recertification assessments included, "will follow up as needed to assist with community resources, education on disease process and to provide emotional and psychosocial support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial psychosocial and recertification assessments. The plan of care did include problems, goals and interventions for advanced directives and power of attorney documents. Record #97010: The initial nursing assessment 12/14/21 included the identified problems of "comfort and pain management, crackles, productive cough and chronic constipation". The clinical record did not contain a plan of care which identified goals or planned interventions based on these problems identified in the initial nursing assessment. Pain medication was ordered on 12/14/21. The initial psychosocial assessment 12/16/21 included, "provided emotional support and empathetic listening". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial psychosocial assessment. The initial spiritual assessment was not completed. Record #37415: The patient elected hospice 12/27/21 and revoked hospice services 4/15/22. The initial nursing assessment 12/27/21 included the identified problems of "forgetfulness, pain, incontinence and functional and cognitive decline". The clinical record did not contain a plan of care which identified goals or planned interventions based on these problems identified in the initial nursing assessment. Pain medication was ordered on 12/27/21. The initial spiritual assessment 12/31/21 included "will provide monthly spiritual follow up". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial spiritual assessment. The initial psychosocial assessment 12/31/21 included, "will follow up with patient to assist with community resources, education on disease process and to provide emotional and psychosocial support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial psychosocial assessment. The plan of care did include goals and interventions for "advanced directives and POLST". Record #40689: The patient elected hospice 9/18/21 and revoked hospice services 12/13/21. The initial nursing assessment 9/18/21 included the identified problems of "leg swelling, shortness of breath and non-compliance medications". The clinical record did not contain a plan of care which identified goals or planned interventions based on these problems identified in the initial nursing assessment. Pain medication and oxygen were ordered on 9/18/21. The plan of care did include goals and interventions for "CPR". The initial psychosocial assessment 9/22/21 included, "will follow up as needed to assist with community resources, education on disease process and to provide emotional and psychosocial support". The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial psychosocial assessments. Record #33288: The initial psychosocial assessment included, "will follow up as needed to assist with emotional and psychosocial support" and the updated assessment in the "POC IDG Review" 3/9/22 included social worker visit frequency of one time a month. The clinical record did not contain a plan of care which identified goals or planned interventions based on the the initial and updated psychosocial assessments. During interview 4/21/22, the Alternate Administrator and QA Coordinator confirmed the missing nursing, spiritual and psychosocial identified problems, goals and interventions. During interview 4/21/22, the Alternate Administrator stated that staff need training on how to establish the plan of care problem, goal and intervention based on identified problems in the assessments.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure the Interdisciplinary Group reviewed, revised and documented individualized plans of care no less frequently than every 15 days. Record #83447 was reviewed and revealed that a hospice RN did not attend the IDG/IDT meeting held on 4/6/22 to review and revise the plan of care. The "POC IDG Review" 3/6/22 did not include the electronic signature of a hospice RN who attended the IDG/IDT meeting.. During interview 4/21/22, the QA Coordinator stated, "sometimes the RN does not attend" and "IDG's are done by phone". During interview 4/21/22, the Alternate Administrator confirmed the RN is required to attend the IDG/IDT meeting, either by phone or in person. Record #40689 was reviewed and identified the patient elected hospice care 9/18/21 and revoked 12/13/21. The clinical record reviewed revealed the Interdisciplinary Group did not meet and complete the "POC IDG Review" forms during timeframe 11/4/21 through the date of revocation 12/13/21. During interview 4/21/22, the QA Coordinator and Alternate Administrator confirmed the missing "POC IDG Review" forms.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including: Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. This CONDITION was not met as evidenced by review of documents, personnel records and interview. 4 of 7 (57%) applicable personnel records of nurses and social workers revealed the hospice failed to ensure that "core" services were substantially provided directly by hospice employees. Record #21437 was reviewed and identified the contracted social worker's date of hire was 5/1/20. The personnel file included a signed W9 and a signed "Independent Contractor Agreement" dated 5/1/20. Record #59063 was reviewed and identified the contracted social worker's date of hire was 5/1/20. The personnel file included a signed W9 and a signed "Independent Contractor Agreement" dated 5/1/20. Record #96270 was reviewed and identified the contracted RN/Director of Patient Care Designee's date of hire was 4/1/22. The personnel file included a signed W9 and a signed "Independent Contractor Agreement" dated 4/1/22. Record #72345 was reviewed and identified the contracted Hospice RN's date of hire was 4/1/22. The personnel file included a signed W9 and a signed "Independent Contractor Agreement" dated 4/1/22. During interview 4/21/22, the HR Manager confirmed that the two social workers and two nurses are contracted W9 personnel and stated, "The accountant said not do to contracted" but the two social workers and two nurses insisted on being contracted". During a phone interview 4/21/22, the Administrator was aware that social workers and two of the nurses are contracted staff and not direct employed personnel. This is a CMS CONDITION level finding.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. This standard was not met as evidenced by interview and personnel record review. 1 of 1 (100%) applicable Hospice Aide personnel records reviewed revealed the hospice did not ensure the required initial Hospice Aide competency evaluation was completed. Record #81538 was reviewed and the Hospice Aide date of hire was 11/1/21. The "Hospice Aide" competency evaluation form was not completed until 1/7/22 and did not contain the competency evaluation for the required skill of range of motion, urinary catheter care and Hoyer lift while observing the Hospice Aide's performance with a patient or pseudo patient. The hospice aide skills form included that the competency evaluation of range of motion, urinary catheter care and Hoyer lift was completed "V" (verbally). During interview on 4/19/22, the Hospice Aide stated, "Yes, I have completed range of motion, urinary catheter care and Hoyer lift on patients". During interview 4/21/22, the Alternate Administrator stated the aide skills would be completed by observation with a patient or with a pseudo patient.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by interview and clinical record review. 3 of 3 (100%) applicable clinical records of patients with Hospice Aide services revealed the hospice did not ensure the Hospice Aide was compliant with the visit frequency ordered by the Interdisciplinary Group and included in the plan of care. Record #56868 was reviewed and the clinical record revealed the Hospice Aide visit frequency of three times a week on the "POC IDG Review" dated 3/23/22 and 4/6/22. The clinical record was missing one Hospice Aide visit the week of 3/27/22 and missing three Hospice Aide visits the week of 4/3/22. The last Hospice Aide visit note was documented 3/30/22. During interview 4/21/22, the Office Manager stated she attempted to reach the Hospice Aide and as of 4/22/22, the Hospice Aide was not available for interview. During interview 4/21/22, the QA Coordinator and Office Manager confirmed that the Hospice Aide is assigned to visit the patient three times a week. Record #40689 was reviewed and identified the patient elected hospice on 9/18/21 and revoked hospice services 12/13/21. The clinical record revealed the Hospice Aide visit frequency of two times a week on the "POC IDG Review" dated 11/3/21. The clinical record was missing two Hospice Aide visits the weeks of 11/3/21, 11/7/21, 11/14/21, 11/28/21 and 12/5/21. Record #33288 was reviewed and the clinical record revealed the Hospice Aide visit frequency of two times a week on the "POC IDG Review" dated 3/9/22, 3/23/22 and 4/6/22. The clinical record was missing two Hospice Aide visits the weeks of 3/9/22, 3/13/22, 3/20/22, 3/27/22, and 4/3/22. During interview 4/21/22, the Alternate Administrator, QA Coordinator and Office Manager were not aware that the "POC IDG Review" included Hospice Aide visit frequencies. During interview on 4/21/22, the QA Coordinator and Alternate Administrator confirmed the Hospice Aide visit frequencies in the "POC IDG Review" forms and confirmed the missing Hospice Aide visit notes.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. This standard was not met as evidenced by review of clinical records and interview. 6 of 6 (100%) applicable clinical records of patients requiring a face-to-face visit revealed the hospice did not ensure face-to-face encounter visits had occurred between the patient and hospice physician. Record #31552 was reviewed and identified the patient's 4th benefit period started 3/13/22. The clinical record did not contain a face-to-face visit that was completed by a hospice physician or a hospice nurse practitioner prior to, but no more than 30 calendar days prior to, the 4th benefit period recertification. Record #29439 was reviewed and identified the patient's 4th benefit period started 3/11/22. The clinical record did not contain a face-to-face visit that was completed by a hospice physician or a hospice nurse practitioner prior to, but no more than 30 calendar days prior to, the 4th benefit period recertification. Record #98998 was reviewed and identified the patient elected hospice services at the 3rd benefit period on 12/14/21, was recertified in 4th benefit period starting 2/12/22 and recertified in 5th benefit period on 4/13/22. The clinical record did not contain a face-to-face visit that was completed by a hospice physician or a hospice nurse practitioner prior to, but no more than 30 calendar days prior to, the 3rd, 4th and 5th benefit periods. Record #37418 was reviewed and identified the patient elected hospice services at the 3rd benefit period on 12/27/21, and was recertified in 4th benefit period starting 2/25/22. The clinical record did not contain a face-to-face visit that was completed by a hospice physician or a hospice nurse practitioner prior to, but no more than 30 calendar days prior to, the 3rd and 4th benefit periods. Record #97010 was reviewed and identified the patient's 3rd benefit period started 4/6/22. The clinical record did not contain a face-to-face visit that was completed by a hospice physician or a hospice nurse practitioner prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification. Record #56868 was reviewed and identified the patient's 3rd benefit period started 4/10/22. The clinical record did not contain a face-to-face visit that was completed by a hospice physician or a hospice nurse practitioner prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification. During interview on 4/21/22, the QA Coordinator and Alternate Administrator confirmed the missing face-to-face visits. Additionally, during interview on 4/21/22, the Office Manager stated the Medical Director was given a list of patients that required a face-to-face visit.

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 home visit, review of clinical records and interview. 1 of 11 (9%) clinical records reviewed revealed missing physician orders for medications. Record #31552 was reviewed and identified the patient elected hospice care on 1/12/22 with a terminal diagnosis of malignant cancer of the stomach. During home visit 4/21/22, the alert and oriented patent stated that he had his stomach cancer surgically removed 8 years ago and had been told yearly by the physician that he no longer has stomach cancer. The clinical record did not contain physician's orders and/or medications included in the plan of care for medications at time patient elected hospice care. The initial nursing assessment 1/12/22 included, "malignant cancer of the stomach and constipation". There were no medication orders 1/12/22 for constipation, or alternate treatment orders for the constipation. The initial nursing assessment 1/12/22 included "generalized pain with non-pharmacologic measures". On 1/25/22 physician's orders were obtained for Levothyroxine, ARED eye drops and Lubricating Tears. The paper copy clinical record at the hospice and in the patient's home folder contained a "Medication Profile" which was signed and dated 1/12/22 by only the Hospice RN and listed Metoprolol, AREDS 2, Lutein, Ferrous Sulfate, Vitamin B12, Febuxostat, D 500/200mg, Uiticarg Calcium, Fish Oil and D3. During home visit 4/21/22, the patient stated, "I do not have pain but if I did, I would take Tylenol" and "I do have discomfort and numbness in my legs and arms and would like some balm to rub on the skin". Review of the clinical record revealed no physician's orders for Tylenol. The patient's request for balm to apply to the skin for discomfort and numbness was communicated to the QA Coordinator and Alternate Administrator. During home visit 4/21/22, the patient presented his medications and stated he was taking the following medications: Metoprolol, AREDS 2, Lutein, Ferrous Sulfate, Vitamin B12, Febuxostat, D 500/200mg, Uiticarg Calcium, Fish Oil, Levothyroxine, and D3. The clinical record did not contain physician's orders and/or medications included in the plan of care for the following medications: Metoprolol, Lutein, Ferrous Sulfate, Vitamin B12, Febuxostat, D 500/200mg, Uiticarg Calcium, Fish Oil and D3. During interview 4/21/22, the QA Coordinator and Alternate Administrator confirmed the paper format medication profile located in the paper clinical record at the hospice was only signed by the Hospice RN, the clinical record only contained physician's orders for Levothyroxine, ARED eye drops and Lubricating Tears and there were no other medications included in the plan of care.

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.I; and the patient’s record, if requested. This standard was not met as evidenced by interview and clinical record review. 1 of 1 (100%) applicable clinical records reviewed of patients that transferred to another hospice revealed the hospice did not ensure the a Discharge Summary was completed and sent to the receiving hospice. Record #97010 was reviewed and identified the patient was transferred to another hospice on 12/14/21. The clinical record did not contain a completed Discharge Summary. The "Discharge Summary" format in the clinical record was blank. During interview 4/21/22, the QA Coordinator and Alternate Administrator confirmed the "Discharge Summary" was blank.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by interview and clinical record review. 2 of 2 (100%) applicable clinical records reviewed of patients that revoked the election of hospice care revealed the hospice did not ensure a Discharge Summary was completed and forwarded to the receiving hospice. Record #40689 was reviewed and identified the patient revoked the election of hospice care 12/13/21. The clinical record did not contain documentation that a Discharge Summary was completed and sent to the Attending Physician. The "Discharge Summary" format in the clinical record was blank. Record #37418 was reviewed and identified the patient revoked the election of hospice care 4/15/22. The clinical record did not contain documentation that a Discharge Summary was completed and sent to the Attending Physician. The "Discharge Summary" format in the clinical record was blank. During interview 4/21/22, the QA Coordinator and Alternate Administrator confirmed the "Discharge Summary" was blank.