Every finding on record at Spectrum Hospice and Palliative Care, Inc.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, it was revealed that the agency did not ensure that an initial comprehensive assessment was completed within 5 days after election of care to ensure the psychosocial and spiritual needs of the patient were assessed. Clinical Record 2: The election of hospice care was dated 10/17/23. The initial hospice plan of care (POC) effective 10/17/23, included orders for medical social worker (MSW) visits 1 time a month. The MSW assessment was dated 10/26/23 (9 days). The clinical record did not include documentation that explained why the comprehensive assessment was not completed within 5 days after the election of care. Clinical Record 6: The election of hospice care was dated 3/14/23. The initial hospice POC effective 3/14/23, included orders for chaplain visits 1 time a month. The chaplain assessment was dated 3/21/23 (7 days). The clinical record did not include documentation that explained why the comprehensive assessment was not completed within 5 days after the election of care. Clinical Record 10: The election of hospice care was dated 10/14/23. The initial hospice POC effective 10/14/23, included orders for MSW visits 1 time a month. The MSW assessment was dated 11/8/23 (25 days). The clinical record did not include documentation that explained why the comprehensive assessment was not completed within 5 days after the election of care. During an interview on 1/4/24, the administrator confirmed the findings.

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 medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure the drug profile included the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Clinical Record 3 / Home Visit 3: During the home visit on 1/4/23, a review of the assisted living facility (ALF) medication record included medications the following: Alprazolam 0.25mg twice daily; Haloperidol concentrate 2mg/ml 0.5mg every 4 hours, as needed; Lorazepam intensol 2mg/ml 0.5mg every 4 hours, as needed; Morphine Sulfate 100mg/ml 5mg every 2 hours, as needed; and Scopolamine 2.5mg/ml topical gel every 6 hours, as needed. These medications were not listed on the hospice medication profile or the updated plan of care dated 1/2/24. Clinical Record 4 / Home Visit 1: During the home visit on 1/4/23, a review of the ALF medication record included the following: Quetiapine 50mg twice daily; and Quetiapine 50mg daily, as needed. The ALF record contained evidence that the medication orders were changed on 12/20/23. The hospice record included the following: Quetiapine 75mg every morning; and Quetiapine 100mg every evening, The change in orders that were effective 12/20/23 were not listed on the hospice medication profile or the updated plan of care dated 1/2/24. During an interview on 1/4/24, the Administrator confirmed the findings and stated in part, "The nurses should be updating the medication profile at every visit."

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's individualized written plan of care included the treatment necessary to meet the needs of the patient. Clinical Record 1: The nursing assessment documentation from the visit conducted on 12/22/23 included, "Cleansed wound with wound cleanser, pat dry with 4x4 gauze, applied Medi-Honey, then covered with bordered silicone foam dressing." The clinical record did not contain evidence that Medi-Honey was included on the plan of care (POC) dated 12/26/23. Clinical Record 2: The nursing assessment documentation from the visit conducted on 12/9/23 included, "Wound cleansed with wound spray, pat dry, applied zinc oxide 20% ointment then covered with Duoderm." The clinical record did not contain evidence that zinc oxide was included on the POC dated 12/26/23. During a joint record review and interview on 1/4/24, the Administrator confirmed the findings.

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 that are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services should 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 clinical record review, document review, and interview. In 1 of 2 (50%) clinical records reviewed, for bereavement services, it was revealed that the agency did not ensure bereavement services were provided per the plan of care. Agency policy PC.B30, Bereavement Services (revised 5/27/23). stated in part, "Bereavement Services provided include but are not limited to: letters and supportive information provided at one, three, six, nine and thirteen months after the patient's death; support groups; memorial services; bereavement visits and/or calls." Clinical Record 13: Date of discharge was 2/13/23. The bereavement plan of care ordered letters to be sent at three, six, and nine months. However, there was no evidence that the letters were sent as ordered in the plan of care. During an interview on 1/4/24, the Administrator confirmed the finding.

It is required that a hospice aide provides services that are consistent with the hospice aide training. This standard was not met as evidenced by observation, personnel record review, and interview. In 1 of 12 (8%) records reviewed, it was revealed that the agency did not ensure that the hospice aide provided services consistent with the hospice aide training. Agency policy PC.H20, Hospice Aide Assignments and Duties (revised 5/27/23), stated in part, "A hospice aide provides services that are: consistent with the hospice aide's training." Home Visit 3 / Staff 6: During a home visit on 1/4/24 with the hospice aide, it was revealed that the aide helps with the patient's right lower extremity wound care, when the nurses are busy. During an interview the Aide stated, "I was a nurse in the (country) and have worked in the operating room. I will change the dressings, clean the wound with wound wash, and reapply the dressing if it comes off or if it gets dirty." The aide plan of care dated 11/17/23, did not include cleaning the wound or reapplying dressing. During an interview on 1/4/24, the Clinical Supervisor/Registered Nurse stated,, "She (the aide) will help with wound care if needed." Personnel Record 6: Aide with 4/13/22 date of hire. The personnel record for the hospice aide did not contain evidence of training or assessment of competency for wound care. During an interview on 1/4/24, the Administrator confirmed the finding and stated there was no documentation of competency for wound care.

It is required that hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 12 (8%) clinical records reviewed, it was revealed that the agency did not ensure hospice aide documentation complied with hospice policies and procedures. Agency policy PC.D25, Documentation Requirements (revised 5/27/23), stated in part, "Documentation is completed by all hospice staff and volunteers whenever: patient/caregiver visits occur." Clinical Record 2: The updated plan of care dated 12/12/23, included hospice aide visits 2 times a week. The clinical record did not contain documentation of the aide visits completed on 12/21/23, 12/23/23, 12/28/23, and 12/30/23. During an interview on 1/3/24, the Administrator confirmed the finding and stated, "The visits were done. We are behind in documentation."

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed, that received hospice aide services, it was revealed that the agency did not ensure a registered nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided and to ensure that the services ordered met the patient's needs. Clinical Record 3: The Initial plan of care (POC) dated 11/17/23, included orders for hospice aide visits 2x/week. Hospice aide visits began on 11/20/23. The clinical record did not contain evidence that hospice aide supervisory visits were completed for visits provided in December 2023. Clinical Record 8: The revised plan of care dated 11/10/2023, included orders for hospice aide visits 3x/week. A hospice aide supervisory visit was completed on 11/25/23. The clinical record did not contain evidence that hospice aide supervisory visits were completed for visits provided in December 2023. During a joint record review and interview on 1/4/24, the administrator confirmed the findings.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient and contains correct clinical information that is available to the patient’s attending physician and hospice staff and includes the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 10 (50%) clinical records reviewed, it was revealed that the agency did not ensure the clinical record contained clinical notes including the care and services provided. Agency policy PC.D25, Documentation Requirements (revised 5/27/23), stated in part, "Documentation is completed by all hospice staff and volunteers whenever: patient/caregiver visits occur." Clinical Record 2: The updated plan of care effective 12/12/23, included orders for nursing visits 1 time a week. There was no evidence that the nursing visits conducted on 12/22/23 and 12/29/23 were documented. Clinical Record 5: The updated plan of care effective 12/19/23, included orders for nursing visits 1 time a week. There was no evidence that the nursing visits conducted on 12/22/23 and 12/29/23 were documented. Clinical Record 6: The updated plan of care effective 12/19/23, included orders for nursing visits 1 time a week. There was no evidence that the nursing visits conducted on 12/19/23 and 12/26/23 were documented. Clinical Record 7: The updated plan of care effective 12/19/23, included orders for nursing visits 1 time a week. There was no evidence that the nursing visits conducted on 12/22/23 and 12/29/23 were documented. Clinical Record 8: The updated plan of care effective 12/12/23, included orders for nursing visits 2 times a week and chaplain visits 1 time a week. There was no evidence that the nursing visits conducted on 12/19/23, 12/22/23, 12/26/23, and 12/29; and chaplain visits provided on 12/12/23, 12/19/23, and 12/2623, were documented. During an interview on 1/3/24, the Administrator confirmed the finding and stated, "The visits were done. We are behind in documentation."

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 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 and 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 2 of 2 (100%) clinical records reviewed, for a live discharge, it was revealed that the agency did not ensure that a discharge 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, and any other documentation was provided upon discharge to assist in the post-discharge continuity of care. Clinical Record 11: The election of hospice was dated 2/23/23. The patient was discharged to another hospice on 5/10/23. There was no evidence that a discharge summary was provided to the receiving facility or the attending physician. Clinical Record 12: The election of hospice was dated 1/13/23. The patient was discharged on 12/1/23, due to an out-of-state residential move. There was no evidence that a discharge summary was provided to the receiving facility or the attending physician. During a joint record review and interview on 1/4/24, the Administrator confirmed the findings.

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. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records of patients who expired while receiving hospice services, review revealed the agency did not ensure that documented evidence was present in the records to confirm that bereavement services were offered and/or provided to the patients' families. The agency's policy stated in part: "The hospice provided bereavement services to the family, caregivers and/or significant others of deceased patients for thirteen months following the patient's death. Bereavement services provided include but are not limited to letters and supportive information provided at one, three, six, nine and thirteen months after the patient's death; support groups; memorial services; bereavement visits and/or phone calls." Clinical Record 5: This patient was admitted to hospice on 3/18/2022 with a diagnosis of Alzheimer's Disease and expired on 6/8/2022. There was no documented evidence in the clinical record to confirm that the family received any contact from the hospice to offer bereavement support services. In an interview with the administrator, she stated that the family refused bereavement support, however this conversation was not documented in the clinical record. Clinical Record 4: This patient was admitted to hospice on 3/19/2022 with a diagnosis of Parkinson's Disease. The patient expired on 10/29/2022. There was no documented evidence in the clinical record to confirm that the family received any bereavement phone calls or other contact. In an interview with the administrator, she stated that the family was called, and they refused bereavement services. This conversation with the family was not documented in the clinical record. Agency policy states in part: "The hospice provided bereavement services to the family, caregivers and/or significant others of deceased patients for thirteen months following the patient's death." "Bereavement services provided include but are not limited to letters and supportive information provided at one, three, six, nine and thirteen months after the patient's death; support groups; memorial services; bereavement visits and/or phone calls."

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by record review and interview and identified the agency failed to ensure medication profiles were completed (L530) and failed to ensure comprehensive assessment were updated as the patient condition changed or as required (L533).

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by review of records and interview. 1 of 3 (33%) of records reviewed revealed that there was no medications listed for the patient in the medication profile. Record #22503 was reviewed and revealed that no medications were listed on the drug profile. This patient was admitted 11/30/2021 and the RN initial comprehensive assessment documented that the patient complained of pain in both knees at 5/10, and that the patient was receiving oxygen PRN. The Clinical Supervisor was interviewed on 1/3/2022 and stated that the ALF that the patient resided in gave the patient all the medications so the medications were not included on the medication profile.

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, 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 IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by record review and an interview. 3 of 3 (100%) records reviewed revealed the update of the comprehensive assessment was not completed as the patient condition changed or as required. Records #99900, #22503, and #51462 were reviewed and revealed there was no documentation of IDG meetings, which would have included comprehensive assessments. The Clinical Supervisor was interviewed on 1/3/2022 and stated that the clinical team had conversations with the Hospice Medical Director, but the IDG did not update the comprehensive assessment as frequently as the condition of the patient required or no less than every 15 days.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by record review and interview and identified the agency failed to ensure the visit frequency ordered on the plan of care was followed (L543); failed to ensure that drugs and treatments necessary to meet the needs of the patient were not included in the POC (L549); failed to ensure that the Interdisciplinary Group reviewed, revised, or documented the individualized care plan as the patient condition changed or as required, or no less than every 15 days (L552); failed to ensure information was shared with the ALF that was providing services to the hospice patient (L558). .

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), the patient or patient representative, the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a clinical record review and interview. 1 of 3 (33%) records reviewed revealed the visit frequency ordered on the plan of care was not followed. Record #22503 was reviewed and revealed with SN frequency orders written for 1XW. The record did not have documentation of a SN visit for the week of 12/19/2021-12/25/2021. The Clinical Supervisor was interviewed on 1/3/2022 and indicated that the staff did not follow the POC.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by review of records and interview. 1 of 3 (33%) records reviewed revealed that drugs and treatments necessary to meet the needs of the patient were not included in the POC. Record #22503 was reviewed and revealed the RN initial comprehensive assessment completed 11/30/2021 documented that the patient had pain in both knees at a pain level of 5/10. This patient also had shortness of breath, experienced combativeness, and had a wound on the left foot. The POC did not include drugs or treatments for these problems. The Clinical Supervisor was interviewed 1/3/2022 and stated that the ALF the patient resided in gave the patient all the medications so she did not include the medications in the POC. She stated that the wound was small and the treatment was NS and "just cleaning up". She confirmed that the POC did not include the drugs and treatments necessary for palliation and management of the wound.

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. A revised plan of care includes information from the patient’s updated comprehensive assessment; record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by record review and interview. 3 of 3 (100%) records reviewed revealed that the Interdisciplinary Group did not review, revise, or document the individualized care plan as the patient condition changed or as required, or no less than every 15 days. THIS IS A CONTINUED REQUIRED ACTION Records #99900, #22503, and #51462 were reviewed and revealed there was no documentation of IDG meetings, which would have included a review of the patient's plan of care. The Clinical Supervisor was interviewed on 1/3/2022 and stated that the clinical team had conversations with the Hospice Medical Director, but the IDG did not update the comprehensive assessment as frequently as the condition of the patient required or no less than every 15 days. This did not allow for the opportunity to review and revise, as needed, the plan of care for the patients.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that: Sharing of information occurs and is ongoing with other non-hospice healthcare providers providing services unrelated to the terminal illness and related conditions. This standard was not met as evidenced by review of records and interview. 1 of 3 (33%) records reviewed revealed the hospice did not ensure that information was shared with the ALF that was providing services to the hospice patient. Record #22503 was reviewed and revealed the patient resided in an ALF. No documentation could be found that the hospice communicated or exchanged information with the ALF. The Clinical Supervisor was interviewed 1/3/2022 and stated that the hospice staff had conversations with the ALF, but did not document the sharing of information, nor was there any further information to provide.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by record review and interview. 1 of 3 (33%) records reviewed revealed RN failed to met the assessed needs of the patient. THIS IS A CONTINUED REQUIRED ACTION. Record #22503 was reviewed and identified that the RN initial assessment completed 12/1/2021 documented that the patient was having pain and shortness of breath and was also combative. There was no documentation that the hospice nurse provided comfort care for the patient. There was no medications listed on the medication profile for symptom control. When the Clinical Supervisor was interviewed on 1/3/2022, it was indicated that the ALF where the patient resided was giving the comfort medications and no further information was provided.

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: Communication skills; 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; Normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient: Observation, reporting, and documentation of patient status and the care or service provided; Basic infection control procedures; Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; Maintenance of a clean, safe, and healthy environment; Recognizing emergencies and the knowledge of emergency procedures and their application; The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; Adequate nutrition and fluid intake; Any remaining task(s) that the hospice chooses to have an aide perform. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by a personnel record review and an interview. 1 of 1(100%) applicable personnel records revealed that the competency evaluation documentation of observed skills was not clear. it was unclear which patient received each type of bath and what type of shampoo was completed. Record #73177: The HHA Competency document dated 3/18/2021, included bed bath, sponge bath, and tub bath, all dated 3/18/21. There was no form of patient identification documented. Hair Shampoo: Sink, tub, bed (circle one): none are circled to indicate it was observed. The method of observation was documented as PC (during patient care). There was a documented "slash" indicating the task was completed. There was no form of patient identification documented. The signature of the supervisor conducting this observation was not legible and there were no credentials. This was discussed with the administrator. The documentation was reviewed with the Administrator and she confirmed this finding.

It is required that a hospice aide provides services, ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by record review. 1 of 1 (100%) applicable records of patients that received aide services revealed the hospice aide did not provide services as included in the plan of care. Record #22503 was examined and revealed that the HA visit frequency order written 12/1/2021 was 2XW. The hospice aide notes for 12/6/2021 and 12/26/2021 did not document any personal care as ordered in the hospice aid care plan.

It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator is an employee of the organization; informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities; has the education and experience as required by the governing body. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by interview and documentation review the hospice did not ensure the acting Alternate Administrator was appointed, oriented, or agreed to the position of Alternate Administrator. In an interview with the Administrator on 1/3/2022, it was stated that the Clinical Supervisor was responsible when the Administrator was not available. The Administrator could not provide evidence that the Clinical Supervisor had been appointed as Alternate Administrator by the governing body. The job description of the Clinical Supervisor was reviewed and revealed the job description did not include the responsibility of the Alternate Administrator when the Administrator was not available.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition; related diagnosis(es), if any; current subjective and objective medical findings; current medication and treatment orders; and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by review of records and interview. 3 of 3 (100%) of records reviewed revealed the CTI did not include the following: the primary diagnosis, related diagnoses, current subjective and objective medical findings, nor current medication and treatment orders. Record #99900 was reviewed and revealed that the CTI was signed and dated on 11/30/2021, but did not include the following: the primary diagnosis, related diagnoses, current subjective and objective medical findings, nor current medication and treatment orders. Record #51462 was reviewed and revealed that the CTI was signed and dated on 12/9/2021, but did not include the following: the primary diagnosis, related diagnoses, current subjective and objective medical findings, nor current medication and treatment orders. Record #22503 was reviewed and revealed that the CTI was signed and dated on 12/1/2021, but did not include the following: the primary diagnosis, related diagnoses, current subjective and objective medical findings, nor current medication and treatment orders. The Clinical Supervisor was interviewed on 1/3/2022 and indicated that the CTI's were not completed and had no further information to provide.

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: any advance directives. This standard was not met as evidenced by review of records and interview. 1 of 3 (33%) records reviewed revealed the hospice did not ensure the clinical record contained an advance directive. Record #22503 was reviewed and identified the patient elected hospice care on 12/1/2021. The clinical record did not contain an advance directive. The Administrator was interviewed by phone on 1/3/2022 and stated there was no advance directive within the records identified nor was there any additional information to provide.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by record review and interview. 3 of 3 (100%) records reviewed revealed there was no documentation that a copy of the agency policy and procedure for the safe use and disposal of controlled medications was given to the patient/family at the time of admission. THIS IS A CONTINUED REQUIRED ACTION. Records #99900, #22503, and #51462 were reviewed and identified that there was no documentation that the hospice provided a copy of the hospice written policy and procedure on the management and disposal of controlled drugs to the patient/family/patient's legal representative. The Clinical Supervisor was interviewed on 1/3/2022 and stated there was no documentation in the clinical records that the hospice provided a copy of the hospice written policy and procedure on the management and disposal of controlled drugs to the patient or family nor was there any additional information to provide.