Every finding on record at Solace Valley Healthcare LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed revealed the hospice did not ensure that the medications were reviewed as part of the comprehensive assessment and updated to the drug profile when changes are made to an existing medication. Clinical Record 1: The patient elected hospice care on 10/30/2023. During the home visit on 07/24/2024 with the registered nurse (RN) (Personnel Record 1), a medication review was completed comparing the hospice medication profile dated 07/23/2024 to the patient’s medication bottles and group home medication list presented by the group home caregiver and owner. Orders were in place for Lorazepam 2mg/ml take 0.75ml (1.5mg) every 4 hours as needed for anxiety and Trazodone 100mg, take 100mg at bedtime as needed for insomnia. The hospice medication profile reviewed on 07/23/2024 revealed Lorazepam 2mg/ml take 0.25ml (0.5mg) every 4 hours as needed for anxiety and Trazodone 50mg take 50mg daily at bedtime, both effective 10/30/2023. The RN provided evidence of a signed physician’s order effective 05/31/2024 for the increase in Lorazepam and Trazodone orders to Lorazepam 2mg/ml take 0.75ml (1.5mg) every 4 hours as needed for anxiety and Trazodone 100mg, take 100mg at bedtime as needed for insomnia. There was no documented evidence that the physician’s order received on 05/31/2024 to increase the Lorazepam and Trazodone were updated to the hospice medication profile. During a joint record review and interview on 07/24/2024, the Administrator agreed that the new medication orders were not updated on the hospice medication profile.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which the patient was a live discharge, revealed that the hospice did not ensure that the discharge summary forwarded to the patient’s attending physician included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders. Clinical Record 4: The patient elected hospice care on 07/27/2023 and was discharged (extended prognosis) on 05/22/2024. There was no documented evidence that the discharge summary faxed to the community attending physician included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; and the patient’s latest physician orders. During a joint review of the record and interview on 07/24/2024, the Administrator agreed there was no documented evidence that the discharge summary faxed to the patient’s attending physician included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; and the patient’s latest physician orders.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed the organization did not ensure the comprehensive assessment included an initial bereavement assessment. Clinical Record 2: This patient elected hospice services on 08/22/2023. A clinical record review on 04/16/2024 revealed no initial bereavement assessment completed as of 04/16/2024. During a joint clinical record review and interview with the Administrator/Director of Clinical Services on 04/16/2024, the administrator noted that the patient/family had declined spiritual counseling services upon admission and this assessment is typically completed by the spiritual counselor. A discussion occurred related to who is qualified to complete the initial bereavement assessment and the administrator acknowledged that the social worker or registered nurse can complete this.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement and physician certification and recertification of terminal illness. This CONDITION was not met as evidenced by clinical record review, document review and interview. The hospice failed as follows: - To ensure that there were signed copies of the notice of patient rights in accordance with §418.52 and election statement in accordance with §418.24 [HSIM 3.I/L673]; and - To ensure that the record contained physician certification and recertification of the terminal illness. The cumulative effect of these systemic problems resulted in the inability of the hospice to ensure safe, quality patient care. This is a CMS Condition level finding at 418.100 - Clinical Records

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 signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 5 (60%) clinical records reviewed revealed the agency did not ensure the hospice election statement had been completed in accordance with 418.24 Document 2: Medicare Code of Federal Regulation (CFR) 418.24 related to the election of hospice care states in part, "the election statement must include [...] [i]dentification of the particular hospice [..., and] [t]he effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement." Clinical Record 3: This patient elected hospice services on 07/27/2023. The Election of Hospice Medicare Benefit and Patient Authorization was signed by a family member and the date signed was left blank. The statement, "Having been advised by my physician of my diagnosis and prognosis, I [BLANK], request admission to the [BLANK] Hospice Program for care" was left blank. Additionally, the statement, "I request that authorization benefits begin on [BLANK] (Start of Care Date)" was left blank. Clinical Record 5: This patient elected hospice services on 06/05/2023. The Election of Hospice Medicare Benefit and Patient Authorization was signed by a family member and the date signed was left blank. The statement, "Having been advised by my physician of my diagnosis and prognosis, I [BLANK], request admission to the [BLANK] Hospice Program for care" was left blank. Additionally, the statement, "I request that authorization benefits begin on [BLANK] (Start of Care Date)" was left blank. Clinical Record 4: This patient elected hospice services on 09/26/2023. The Election of Hospice Medicare Benefit and Patient Authorization was signed by a family member on 09/26/2023. The statement, "Having been advised by my physician of my diagnosis and prognosis, I [blank], request admission to the [blank] Hospice Program for care" was left blank. Additionally, the statement, "I request that authorization benefits begin on [blank] (Start of Care Date)" was left blank. During the daily wrap up conference on 04/17/2024, the code of federal regulation related to the election statement was reviewed. The identified election statements were reviewed, and the Administrator acknowledged that the information was missing and that the forms were incomplete. The Administrator then asked, "Should we get new elections signed or should we just fill in the effective dates?"

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) applicable clinical records reviewed for patient's requiring a face-to-face encounter, it was revealed the organization did not ensure the recertification of terminal illness met requirements as defined by organizational policy. Document 3: Organizational policy number 1-007.A (Revised May 2023), stated in part, "The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within thirty (30) days prior to the hospice recertification for the third and all subsequent benefit periods." Additionally, "The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician." Clinical Record 2: This patient elected hospice services on 08/22/2023. A Certification of Terminal Illness (CTI) for benefit period three (3) from 02/18/2024 through 04/17/2024 stated in part, "Certification is based on Face to Face Encounter Visit Date [BLANK]". The hospice physician signed electronically on 02/18/2024. A face-to-face document attached to the record titled "Recertification History and Physical" includes no date of encounter and was signed by a nurse practitioner (no date) who is not an employee of the hospice. A CTI for benefit period four (4) beginning on 04/18/2024, stated in part, "Certification is based on Medical history, record and patient status [and] Team Assessment" and the box for Face to Face Encounter was left unchecked. The hospice physician signed electronically on 04/05/2024. A face-to-face encounter for hospice was signed by a nurse practitioner, who is not a hospice employee, on 04/08/2024 (three days after certification was signed by the physician) and did not include a date of encounter. Clinical Record 3: This patient elected hospice services on 07/27/2023. A Certification of Terminal Illness (CTI) for benefit period three (3) from 01/23/2024 through 03/22/2024 stated in part, "Certification is based on Face to Face Encounter Visit Date [BLANK]". The hospice physician signed electronically on 01/12/2024. A face-to-face encounter for hospice was signed by a nurse practitioner, who is not a hospice employee, on 01/26/2024, three days after the start of the benefit period, but did not include the date of encounter. A CTI for benefit period four (4) from 03/23/2024 through 05/21/2024, stated in part, "Certification is based on Face to Face Encounter Visit Date [BLANK]". The hospice physician signed electronically on 03/23/2024. A face-to-face encounter for hospice was signed by a nurse practitioner, who is not a hospice employee, and was not dated. During an interview with the Administrator/Director of Clinical Services on 04/17/2024, it was stated by the Administrator that the Nurse Practitioners informed her they were able to do face to face visits for the hospice agency. When asked for clarification if they are employees or contractors, the administrator clarified they are "1099" contractors. The agency policy was reviewed with the administrator as well as Medicare's Code of Federal Regulation 418.22 on 04/18/2024, and the Administrator agreed that the agency was not following their policy related to nurse practitioner's needing to be employees. She also acknowledged that the nurse practitioners were not following agency policy related to dating their encounter. The Administrator stated on 04/18/2024 that she is working on "hiring the nurse partitioner's immediately" and onboarding them as hospice employees.