Every finding on record at St. Mary's Hospice Services, Inc.

It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by document review and interviews with the Human Resources Coordinator and the Chief Operations Officer/Executive Director, which revealed that the governing body failed to ensure the agency implemented the emergency preparedness program and emergency preparedness (EP) plan in the following areas: Failed to ensure emergency preparedness plan was reviewed and updated every two years [HSEP.2.D/E4/418.113(a)]; Failed to ensure the emergency plan was based on a documented, facility-based and community-based risk assessment [HSEP.2.D/E6/418.113(a)(1)]; Failed to ensure emergency preparedness communication plan was reviewed and updated at least every two years [HSEP.4.D/E29/418.113(c)]; and Failed to ensure all new hospice employees and those providing services under arrangement, received initial training in EP policies and procedures consistent with their expected roles [HSEP.5.D/E37/418.113(d)(1)]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the agency's emergency preparedness plan revealed that the agency did not ensure that the plan was reviewed and updated at least every two years. A review of the agency's 'Emergency Management Plan' included a hazard vulnerability analysis (HVA) dated 01/20/2022. This was the only document provided that included a date. The emergency preparedness plan documentation lacked evidence that it had been reviewed and updated at least every two years. During an interview with the Chief Operations Officer/Executive Director, on 04/17/2025, he stated that no additional HVAs or other updates to the 'Emergency Management Plan' had been conducted since 01/20/2022. A review of the agency's emergency management plan revealed that the agency did not ensure that the emergency management plan and the agency's hazard vulnerability analysis were updated annually as per the agency's policy.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. A review of the agency's emergency preparedness plan revealed that the agency did not ensure that the hazard vulnerability analysis was updated annually as per the agency's policy. Agency Policy (no policy number), Hazard Vulnerability Analysis (HVA), stated in part, "The HVA will be conducted initially when developing the Emergency Preparedness Plan, upon identification of any new external risk factor, when beginning a new service, and annually.” A review of the agency's Emergency Management Plan revealed that the most recent HVA was done on 01/20/2022. There was no documented evidence that the HVA had been reviewed or updated since that date. During an interview with the Chief Operations Officer/Executive Director, on 04/17/2025, he stated that no additional HVAs or other updates to the Emergency Management Plan had been conducted since 01/20/2022.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan, including all contact information, is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the agency's ‘Emergency Management Plan’ revealed that the agency did not ensure that the communication plan, including all contact information, is reviewed and updated at least every two (2) years. The communication plan provided by the agency, as part of the emergency management plan did not include a documented date of review. A review of the contact information provided revealed that it included multiple staff members that were no longer employed and was not updated to include newly hired staff. During an interview with the Chief Operations Officer/Executive Director, on 04/17/2025, he stated that no updates to the emergency management plan had been conducted since 01/20/2022.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes, for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles. This standard was not met as evidenced by document review, interview and personnel record review. In 4 of 4 (100%) personnel records reviewed for staff hired in the last three years, it was revealed that the agency did not ensure that new hospice employees and those providing services under arrangement received initial training in emergency preparedness policies and procedures. Agency Policy No. 7-001.3, Emergency Management, stated in part, "Organization leadership will provide for orientation and education of all personnel regarding participation in the emergency management plan. Education will be provided during orientation and annually thereafter." PERSONNEL RECORD 2: A review of the personnel record for this licensed vocational nurse who was hired on 05/16/2022 revealed no documented evidence that training in the agency's emergency management policies and procedures was provided upon hire. PERSONNEL RECORD 3: A review of the personnel record for this registered nurse who was hired on 06/10/2024 revealed no documented evidence that training in the agency's emergency management policies and procedures was provided upon hire. PERSONNEL RECORD 8: A review of the personnel record for this medical director who was contracted on 06/29/2022 revealed no documented evidence that training in the agency's emergency management policies and procedures was provided upon execution of the contract. PERSONNEL RECORD 10: A review of the personnel record for this volunteer who was enrolled on 03/06/2025 revealed no documented evidence that training in the agency's emergency management policies and procedures was provided upon assignment or prior to the staff member providing services. During an interview with the agency's Volunteer Coordinator/Human Resources Coordinator (Personnel Record 5) on 04/16/2025, she stated that she was unaware that training on the agency's emergency management plan was required upon hire and/or at orientation.

It is required that the written Patient Bill of Rights includes the right to choose his or her attending physician. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's right to choose his or her own attending physician was provided. CLINICAL RECORD 1: The hospice consent dated 09/12/2024, included an area for the patient/representative to select their attending physician or decline selection; this section was left blank. CLINICAL RECORD 2: The hospice consent dated 01/01/2024, included an area for the patient/representative to select their attending physician or decline selection; this section was left blank. CLINICAL RECORD 17: The hospice consent dated 09/20/2024, included an area for the patient/representative to select their attending physician or decline selection; this section was left blank. CLINICAL RECORD 19: The hospice consent dated 10/30/2024, included an area for the patient/representative to select their attending physician or decline selection; this section was left blank. During joint clinical record review and interview with the Director of Quality on 04/16/2025 and 04/17/2025 it was found that during the admission process it was not documented that the patient was given the right to choose his or her own attending physician in these records. During joint clinical record review and interview with the director of quality on 04/16/2025 and 04/17/2024 it was found that during the admission process it was not documented that the patient was giving the right to choose his or her own attending in clinical record #1, clinical record #2, clinical record #17, and clinical record #19.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC); Herbal remedies; and Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 2 (100%) clinical records reviewed, of patients residing in a skilled nursing facility, it was revealed that the agency did not ensure that the hospice drug profile was reconciled with the facility drug profile to ensure the medication review included the patient’s current medications. HOME VISIT 1/ Clinical Record 1: The patient elected the hospice benefit on 09/12/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a skilled nursing facility (SNF). During a joint visit with the Social Worker (Personnel Record 1), the hospice and SNF drug profiles were compared. The SNF drug profile included Levalbuterol HCL Inhalation Nebulization Solution 1.25 mg/3ml, 1 vial, inhale orally via nebulizer every 6 hours as needed for shortness of breath or wheezing. On the hospice profile, the directions were to inhale 1 vial 2 times a day as needed and at bedtime for shortness or wheezing. The SNF drug profile listed Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5.25 mg/act. Give 2 puff by mouth two times a day for COPD using a spacer. The hospice profile had the directions listed as 1 puff daily. The SNF drug profile listed Buspirone HCI tablet 15mg give 1 tablet by mouth three times a day. The hospice profile listed 10mg two times a day. Also listed on the SNF drug profile was Culturelle Oral Capsule give 1 capsule by mouth two times a day for supplement, cranberry oral tablet 450mg give 1 tablet by mouth one time a day, ibuprofen oral tablet 200mg give 2 tablets by mouth every 6 hours as needed or left elbow to arm pain swelling; these medications were not included on the hospice drug profile. The hospice drug profile also included Clindamycin HCI Oral 300mg, one tablet, four times a day for 5 days (started on 11/12/2024) the medication was not discontinued from the drug profile. Metronidazole powder bid (twice a day), apply to right axilla twice a day prn started on 08/29/2024, and Celebrex 200mg take 1 capsule bid for migraine started 05/15/2024 were listed on the Hospice profile, but not on the SNF profile. In an interview with the Director of Quality on 04/16/2025, she confirmed that the drug profiles were not reconciled to match each other, and the hospice medication review did not include the current medications being taken by the patient. HOME VISIT 2/Clinical Record 2: The patient elected the hospice benefit on 01/01/2025 with a diagnosis of chronic obstructive pulmonary disease. The patient resided in a skilled nursing facility (SNF). A patient visit was made with the Registered Nurse (RN) (Personnel Record 3) on 04/16/2025. During a review of the SNF drug profile, it was found that the profile was missing Alprazolam 0.5mg give 1 tablet by mouth two times a day PRN (as needed) for anxiety; hold for sedation. In an interview with the RN, she confirmed that the SNF drug profile was missing the updated alprazolam order.

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 assessment update is completed as frequently as the condition of the patient requires or no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure that the comprehensive assessment was updated no less frequently than every 15 days. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/04/2025 with a diagnosis of nontraumatic subarachnoid hemorrhage. The Registered Nurse completed a comprehensive assessment on 02/06/2025. The next comprehensive assessment was due on 02/21/2025 but was not completed until 03/03/2025 (25 days). In an interview with the Clinical Director and Director of Quality, they could not find any documented evidence why the comprehensive assessment was not completed on time.

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 clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure that the plan of care included planned interventions based on problems identified in the comprehensive assessments. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/10/2024 with a diagnosis of Alzheimer’s Disease. The RN documented in on-going nursing assessments that the patient had shortness of breath, anxiety, and chronic pain. On the plans of care dated 02/21/2024 and 03/06/2024, there was no documented evidence of planned interventions for shortness of breath, anxiety or the chronic pain. In an interview with the Director of Quality, it was agreed that the plans of care were missing interventions.

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, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/12/2024 with a diagnosis of chronic obstructive pulmonary disease and a secondary diagnosis of chronic back pain. The patient was receiving oxycodone, Voltaren gel, and Celebrex. During review of the plan of care dated 03/26/2025, the goal listed for the patient was "Patient's pain will remain at a comfortable level during care. Patient/CG verbalize understanding and their involvement in patient care and are in agreement with the plan of care." This was not a measurable goal. In an interview with the Director of Quality and the Clinical Director, it was agreed that these were not measurable outcomes. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/01/2024 with a diagnosis of chronic obstructive pulmonary disease. On the plan of care (POC) dated 04/02/2025, pain was identified as a problem for the patient. The patient was currently receiving Celebrex and oxycodone for pain. Outcome goals listed for patient were "patient's pain will remain at comfortable level during care. Patient/CG verbalize understanding and their involvement in the patient care and are in agreement with the POC." During an interview and joint clinical review with the Director of Quality, she agreed that the goals listed were not measurable.

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. In 4 of 19 (21%) clinical records reviewed revealed that the agency did not ensure that the individualized care plan was reviewed, revised, and documented no less frequently than every 15 calendar days, by the Interdisciplinary Group (IDG). CLINICAL RECORD 1: The patient elected the hospice benefit on 09/12/2024 with a diagnosis of chronic obstructive pulmonary disease. During review of the most current certification period, an IDG meeting was documented on 03/26/2025. The next IDG documentation was due on 04/09/2025. In a joint review of the clinical record and interview with the Director of Quality, she confirmed that there was no documentation in the clinical record for an IDG meeting that should have been held on or before 04/09/2025. The clinical record lacked documented evidence the plan of care was reviewed and/or revised for this 15-day period. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/10/2024 with a diagnosis of congestive heart failure. An IDG meeting was documented on 07/10/2024, and the following IDG documentation was due on 07/24/2024. In a joint review of the clinical record and interview with the Director of Quality, she confirmed that there was no documentation in the clinical record for an IDG meeting that should have been held on or before 07/24/2024. The clinical record lacked documented evidence the plan of care was reviewed and/or revised for this 15-day period. CLINICAL RECORD 15: The patient elected the hospice benefit on 11/19/2024 with a diagnosis of heart failure. An IDG meeting was documented on 12/18/2024; there was no documented evidence of updated plans of care or IDG meetings on 01/01/2025 or 01/15/2025. During an interview with the Director of Quality, she agreed that this documentation was not in the clinical record. The clinical record lacked documented evidence the plan of care was reviewed and/or revised for these 15-day periods. CLINICAL RECORD 16: The patient elected the hospice benefit on 10/15/2024 with a diagnosis of essential hypertension. An IDG meeting was documented on 12/18/2024. There was no documented evidence of an IDG meeting held on or before 01/01/2025, which is when it would have been due. During an interview with the Director of Quality, she confirmed there was no documented IDG meeting. The clinical record lacked documented evidence the plan of care was reviewed and/or revised for this 15-day period.

It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data elements abstracted and aggregated from comprehensive patient assessments are used in quality assessment and improvement. Data collected is used to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure that the data collected was used to identify opportunities and priorities for improvement. A review of the QAPI program and an interview with the Director of Quality were conducted on 04/17/2025. During this time, QAPI reports were reviewed and discussed. The QAPI policy was reviewed and discussed. Data collected and reports ran for QAPI were in a binder that was reviewed with the Director of Quality. There was no documented evidence that the agency was using the collected data to monitor quality of care or identify opportunities and priorities for improvement. The Director of Quality stated, "We mostly just do education for the staff. We have identified some areas for improvement, but we have not initiated a performance improvement plan. We have been working on starting some but just haven't gotten to it." When discussed with the Administrator at the end-of-day conference on 04/17/2025, he reported he was aware that the agency did not have any performance improvement plans in action. A review of the QAPI program and an interview with the director of quality were conducted on 04/17/2025. During this time, QAPI reports were reviewed and discussed. The QAPI policy was reviewed and discussed. Data collected and reports ran for QAPI were in a binder that was reviewed with the director of quality. There was no documented evidence that the agency was using the collected data to monitor quality of care or identify opportunities and priorities for improvement. The director of quality She stated, "We mostly just do education for the staff. We have identified some areas for improvement, but we have not initiated a performance improvement plan. We have been working on starting some but just haven't gotten to it." When discussed with the administrator at the end-of-day conference on 04/17/2025, he was aware that the agency did not have any performance improvement plans in action.

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 clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's nursing needs were met as identified in the plan of care. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/21/2025 with a diagnosis of atherosclerosis of the coronary artery. On the initial plan of care dated 03/21/2025, nursing visits were ordered one time a week. The initial assessment was documented on 03/21/2025. There was no documented evidence of nursing visits made for the weeks of 03/23/2025-03/29/2025, 03/30/2025-04/05/2025, or 04/06/2025-04/12/2025. The patient expired on 04/11/2025. There was no documentation that a death visit was made. In an interview with the Director of Quality on 04/16/2025, she confirmed that the record lacked documentation of if the visits were made or missed. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/08/2025 with a diagnosis of congestive heart failure. The RN documented a visit on 04/11/2025 from 10:15-10:45. There was no concerns documented on this visit. The patient expired in the home on 04/11/2025. There was no documented evidence found that a death visit was made. There was one scheduled on the patient calendar with no documentation attached. In an interview with the Director of Quality she confirmed the documentation was not completed.

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/IID (intermediate care facility/Individuals with Intellectual Disabilities) 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 3 (67%) clinical records reviewed of families receiving bereavement services, it was revealed that the agency did not ensure that bereavement services were provided to the family, per the plan of care, and as outlined in the agency policy. Agency Policy no.9-023, Bereavement Services, stated in part, "Within two weeks after the death of a patient, a sympathy card will be sent to the bereaved. After three weeks, a bereavement letter will be sent to the bereaved, giving support and outlining the hospice bereavement services… If a person is noted as experiencing normal grief, the bereavement counselor will make contact with the bereaved person for ongoing assessment and support at three (3), six (6), and nine (9) months after the patient's death and the anniversary of the patient's death." CLINICAL RECORD 17: The patient expired at home on 12/09/2024. During review of the bereavement plan of care, there were phone calls due to be made on 01/09/2025 and 02/10/2025. During review of the clinical record, no documented evidence was found of these two calls being made. There was also no documented evidence that the agency followed the bereavement policy of follow-up in 3 months. CLINICAL RECORD 19: The patient expired at home on 11/17/2024. The initial phone call was made to the bereaved. During review of the bereavement plan of care, phone calls were due to be made on 12/17/2024 and 01/17/2025. There was no documented evidence found that a sympathy card had been sent or that the follow-up calls had been made. In an interview with the bereavement coordinator on 04/17/2025, she stated, "We make six phone calls on certain dates, that's my part." She explained that someone else keeps the written bereavement plan of care with the assigned tasks for bereavement and makes sure the bereavement sympathy card and letters are sent. The bereavement process was discussed in an interview with the Director of Quality on 04/17/2025, and she confirmed that the agency was not currently following its policy or completing follow-up for bereavement services. The agency policy no.9-023 Bereavement Services states in part, "Within two weeks after the death of a patient, a sympathy card will be sent to the bereaved. After three weeks, a bereavement letter will be sent to the bereaved, giving support and outlining the hospice bereavement services." "If a person is noted as experiencing normal grief, the bereavement counselor will make contact with the bereaved person for ongoing assessment and support at three (3), six (6), and nine (9) months after the patient's death and the anniversary of the patient's death." In an interview with the bereavement coordinator on 04/17/2025, she stated, "We make six phone calls on certain dates, that's my part." She explained that someone else keeps the written bereavement plan of care with the assigned tasks for bereavement and makes sure the bereavement sympathy care and letter are sent. The bereavement process was discussed in an interview with the Director of Quality on 04/17/2025, and she confirmed that the agency was not currently following its policy or completing follow-up for bereavement services.

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. This standard was not met as evidenced by clinical record review and interview. In 8 of 19 (42%) clinical records reviewed, it was revealed that the agency did not ensure that the medical director or physician designee provided a written certification of terminal illness (CTI). CLINICAL RECORD 1: Patient elected the hospice benefit on 09/12/2024. No documented evidence of the initial CTI was found. CLINICAL RECORD 2: Patient elected the hospice benefit on 11/10/2023. Discharged on 12/31/2023 and readmitted on 01/01/2024. The record lacked documented evidence that a CTI was done for certification period 01/01/2024-02/07/2024. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/26/2023; no documented evidence of the initial CTI was found. The patient was discharged on 02/09/2024 and readmitted on 02/10/2024. No documented evidence of the CTI was found. CLINICAL RECORD 6: The patient elected the hospice benefit on 11/16/2024. No documented evidence of the initial CTI was found. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/02/2024. No documented evidence of the initial CTI was found. CLINICAL RECORD 14: The patient elected the hospice benefit on 02/21/2025. No documented evidence of the initial CTI was found. CLINICAL RECORD 17: The patient elected the hospice benefit on 09/20/2024. No documented evidence of the initial CTI was found. CLINICAL RECORD 19: The patient elected the hospice benefit on 10/30/2024. No documented evidence of the initial CTI was found. During joint clinical record reviews and interviews with the Director of Quality, throughout the site visit, it was confirmed that the hospice was unable to provide documented evidence of the certifications of terminal illness for these clinical records. During joint clinical record review and interview with the director of quality if was found and confirmed that there was no written evidence of initial certification of terminal illness for clinical records 1, 2, 3, 6, 7, 9, 12, 14, 17, and 19.

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 described in HCDT 40.I; and a copy of the patient's clinical record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical record reviewed, of a patient that was transferred to another hospice, revealed that the agency did not ensure that a copy of the discharge summary was forwarded to the receiving agency. Agency Policy No. 1-025, Discharge from Hospice Program, stated in part, "A copy of the discharge summary will be sent to the attending physician. If requested, the patient's clinical record will be provided." CLINICAL RECORD 15: The patient elected the hospice benefit on 11/19/2024 with a diagnosis of Heart Failure. The patient was transferred to another hospice agency on 02/11/2025. During the joint review of the clinical record with the transferring RN, no documented evidence was found that a discharge summary was forwarded to the receiving agency. In an interview with the discharging RN on 04/17/2025, the discharge process was discussed, and she stated that no discharge summary was sent to the receiving agency. She stated that she was unaware this was part of the agency's policy. Policy No. 1-025 Discharge from Hospice Program states in part, "a copy of the discharge summary will be sent to the attending physician. If requested, the patient's clinical record will be provided."

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 clinical record review, document review and interview. In 1 of 1 (100%) clinical record reviewed, of patients discharged for no longer terminally ill, it was revealed that the agency did not ensure that a copy of the discharge summary was forwarded to the patient's attending physician. Agency Policy No. 1-025, Discharge from Hospice Program, stated in part, "a copy of the discharge summary will be sent to the attending physician. If requested, the patient's clinical record will be provided." CLINICAL RECORD 16: The patient elected the hospice benefit on 10/15/2024 with a diagnosis of essential hypertension. On 01/06/2025, it was determined by the interdisciplinary team that the patient was no longer terminally ill and was discharged on that day. During a joint review of the clinical record and interview with the Director of Quality, no documented evidence was found that a discharge summary was sent to the patient's attending physician. Policy No. 1-025 Discharge from Hospice Program states in part, "a copy of the discharge summary will be sent to the attending physician. If requested, the patient's clinical record will be provided."

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, document review, and interview. In 2 of 2 (100%) clinical records reviewed, in which a discharge summary was required, it was revealed that the agency did not ensure a discharge summary, including a summary of the patient's hospice stay, was completed on discharge of the patient. Agency Policy No. 1-026, Discharge Summary, stated in part, "All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record." CLINICAL RECORD 15: The patient was discharged on 02/11/2025 due to no longer being terminally ill. During review of the clinical record and discharge documentation, no documented evidence of a discharge summary was found. During a joint review of the clinical record and interview with the Director of Quality and the discharging RN on 04/17/2025, they both confirmed that the discharge summary was not completed at discharge. CLINICAL RECORD 16: The patient was discharged on 01/06/2025 due to going to another agency. During the clinical record review and review of the documentation sent to the receiving agency, no documented evidence of a discharge summary was found. During a joint review of the clinical record and interview with the Director of Quality and the discharging RN on 04/17/2025, they confirmed that the discharge summary was not completed at discharge. Policy no. 1-026 Discharge Summary states in part, "All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record."

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: The most recent hospice plan of care; Hospice election form and any advance directives; Physician certification and recertification of the terminal illness; Names and contact information for hospice staff involved in the patient’s care; 5. Instructions on how to access the hospice’s 24-hour on-call system; Hospice medication information; and Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by document review, observation, and interview. In 2 of 2 (100%) home visits made in a skilled nursing facility (SNF), it was revealed that the agency did not ensure that the SNF was provided with the most recent plan of care and the hospice election form. HOME VISIT 1: The patient elected the hospice benefit on 09/12/2024. During a review of the patient's clinical binder in the facility, no hospice election of benefit form was found, and the last provided plan of care was dated 09/12/2024-11/10/2024. This home visit was made with the Social Worker (Personnel Record 1), and during an interview with her, she could not confirm that the election of benefit form was in the facility. The facility employee could not locate the election of benefit form. HOME VISIT 2: The patient elected the hospice benefit on 01/01/2024. During review of the patient's clinical binder in the facility, no hospice election of benefit form was found and the last provided plan of care in patient binder was dated 11/10/2023-02/07/2024. The visit was done with the Registered Nurse (Personnel Record 3). She directed the surveyor to ask the facility Administrator for the election of the benefit form. The Administrator was unable to locate the election of benefit form.

Observed in Record Review. In 5 of 5 patient records reviewed, Goals were not measurable. Examples include: Pain will remain at comfortable level during care; for dyspnea-patient will receive optimal teaching and support as cardiac and pulmonary function change; for Falls-patient will maintain optimal mobility during care.

Observed in Record Review. In 2 of 2 oxygen patient records, the patient's oxygen order did not contain the frequency of use, e.g. continuous or prn.

Observed in Record Review. In 2 of 5 patient records reviewed, problems identified on the assessment were not on the plan of care. Examples include: The patient (HV1) had a wound requiring wound care; this problem was not identified on the plan of care. In MR1 the patient was admitted with Congestive Heart Failure, had edema and was on oxygen. There was not a problem identified related to the patient's cardiac or respiratory status. This was verified by the Director and DON.

Observed in Document Review. During review of Patient Information Handbook it was noted that the hospice had not provided the patient's with written information about its policies on advance directives. This was confirmed by the administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the goals on the plan of care were not measurable. For example, the following goals were stated: Pt will have optimal teaching and support as cardiac function changes, Nausea and vomiting will be controlled, Pain will remain at a comfortable level during care and Caregiver will demonstrate ability to cope with patient anxiety. This was discussed with the administrator and DON.

Observed in Record Review. In 7 of 11 patient records reviewed, it was noted that the plan of care did not include orders for medical supplies and appliances. For example, in review of record for home visit #2 it was noted that the patient was using oxygen continuously but there was no order for liter flow, frequency or delivery method. In another example, in record review #3 it was noted that the patient was using oxygen continuously but there was no order for liter flow, frequency or delivery method and additionally the patient had a pluerex drainage tube but there were no orders for the management, drainage or dressing related to this appliance. In record review #4 it was noted that there were no orders for peg tube feeding. In record review #5 it was noted that there were no orders for foley catheter to be removed on 1/7/22, no order to reinsert and then no order to d/c on 2/2/22 however this was all documented in the SN notes. Also there were no orders for staple removal or management of scalp wound. In review of record for home visit #3 it was noted that there were no orders for wound care. During the visit the LVN removed a dressing from the patient arm which the wife stated was a skin tear from their dog. In record review #6 it was noted that there was no order for oxygen. In record review #7 it was noted that there was no order for oxygen. This was discussed with the administrator and DON.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that in review of record #1, there was no documentation of the IDG meeting for a period of 22 days following admission. This was confirmed by the DON and discussed with the administrator.

Observed in Record Review. In 6 of 11 patient records reviewed, it was noted that revisions to the care plan had not been made. For example, in review of record for home visit #1 it was noted that the three problems identified on admission in May 2021 were still present on the care plan and no new problems or issues had been added. Additionally in this record the plan of care listed teaching the patient about oxygen usage however the patient was not ordered oxygen. In another example, for record review #1 it was noted that the patient had developed a UTI however the care plan was not updated or revised to add this new problem. In another example, for record review #2 pain was listed as an issue however the patient did not have any pain and the patient was having nutritional issues but this was not on the plan of care. Additionally, the patient developed a UTI but the plan of care was not updated and lastly the LVN documented that the insulin orders had changed due to low morning blood sugars but the plan of care was not updated to reflect this new issue. In record review #3 pain was listed as a problem however the patient did not have any pain issues. In record review #5 the plan of care updates did not reflect issues with foley catheter, breast wound or resolution of scalp wound and lastly new patient infection with start of antibiotic. In review of record #6 it was noted that the patient's issues with dyspnea and use of oxygen and additionally a recent UTI with antibiotic use were not added as revisions to the plan of care. In review of record #7 it was noted that the plan of care was not revised to reflect issues of patient's ascites, dyspnea, pain and psychosocial caregiver issues. This was discussed with the administrator and DON.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that there was no documentation of physician notification when there were changes in the patient's condition. For example, in review of record #5 there was documentation on SN notes that the patient had scalp wound not approximated and draining blood and pus. In the same record the nurse documented that the patient had pulled out her foley two times with balloon intact, and lastly that the staples in the patient scalp were not removed due to patient experiencing pain. This was discussed with the administrator and DON.

Observed in Data Session. During discussion and in review of documents it was noted that the organization had not conducted any PIP projects for 2020, 2021 or 2022. This was confirmed by the administrator and DON.

Observed in Data Session. During discussion and in review of documents it was noted that the organization had not conducted any PIP projects for 2020, 2021 or 2022 therefore there was no documented PIP's. This was confirmed by the administrator and DON.

Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted that during home visit #1 the RN performed the patient physical assessment and then with the same gloved hands she cleaned her equipment and then immediately placed the items back into her nursing bag. This was discussed with the administrator and the DON. Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted that during home visit #1 the RN did not perform hand hygiene after removing her gloves and prior to conducting medication review. This was discussed with the administrator and DON.

Observed in Data Session. During discussion and review of documentation it was noted that there was no formal process in place to collect data regarding hand hygiene compliance therefore no way to demonstrate improvement in compliance. This was confirmed by the administrator and the DON. Observed in Document Review. During review of Infection Control Plan and discussion with leadership it was noted that the organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. This was confirmed by the administrator and the DON. Observed in Document Review. During review of Infection Control Plan and discussion with leadership it was noted that the organization's written infection prevention and control goals did not include the following: Improving compliance with hand hygiene guidelines. This was confirmed by the administrator and the DON. Observed in Document Review. During review of Infection Control Plan and discussion with leadership it was noted that the organization's written infection prevention and control goals did not include the following: Limiting unprotected exposure to pathogens. This was confirmed by the administrator and the DON. Observed in Document Review. During review of Infection Control Plan and discussion with leadership it was noted that the organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. This was confirmed by the administrator and DON. Observed in Document Review. During review of Infection Control Plan and discussion with leadership it was noted that the organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was confirmed by the administrator and the DON.

Observed in Record Review. In 4 of 11 patient records reviewed, it was noted that although the RN had documented supervisory visits every 14 days to include following the plan of care and accuracy of documentation there were incomplete aide visit notes in record reviews #1, 2 and 5 where the aide did not document any of the tasks performed on the patient. Additionally in record review #8 the patient consistently refused the aide visits however the supervisory note indicated that all tasks were being performed and documented appropriately. This was discussed with the administrator and the DON.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.56, 418.60, 418.100.

Observed in Record Review. In 4 of 11 patient records reviewed, it was noted that the initial certification for terminal illness was not in the record. Record review #1 had a start of care date of 3/14/22, record review #8 had a start of care date of 3/18/22, home visit #2 had a start of care date of 3/29/22 and home visit #3 had a start of care date of 3/22/22. This was discussed with and confirmed by the administrator and DON.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the record did not contain completed or accurate documentation. For example, in review of hospice aide notes in record review #1 it was noted that the aide notes were incomplete and did not contain vital signs or what type of bath or care was provided on all visit notes since 1/14/22. In the same record it was noted that the instructions for medication administration on the medication profile the statement administer orally, bucally or rectally for medications such as Metformin, Lisinopril. This was also noted in record review #5 for Mirtazapine to be given either orally, bucally or rectally. In record review #2 the same issue was noted for the hospice aide notes that did not contain vital signs or type of care provided since 12/31/21. Additionally in the same record every skilled nursing note stated that the patient was getting pain relief from Oxycodone however the patient was not ordered this medication and had no pain issues. Lastly in this same record the MSW visit notes were identical for the past two visits. Observed in Record Review. In 2 of 3 home visits conducted, it was noted that the medication list was not accurate. For example, in home visit #1 the following medications were still on the medication profile but were either no longer being given and not available in the home: Lasix, Potassium, Morphine, Alprazolam, Mucinex. Additionally, one medication, Senna was being taken and was not on the medication profile and Tylenol was stated on the medication profile in a 325 mg dosage however in the home the Tylenol was 500mg tablets. During home visit #3 it was noted that the dosage for Sinemet 25-100 was incorrect. The medication profile listed 3 tabs QID however the wife stated that this had been changed several months ago to 1/2 tab TID. This was discussed with the administrator and DON.

Observed in Document Review. In review of the Patient Information Handbook it was noted that the hospice’s policies and procedures for managing the safe use and disposal of controlled medications were not provided to the patient or family. This was discussed with the administrator.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that in the hospice medical director file there was no primary source verification in the file. This was corrected on site and run on day three of the survey.

Observed in Document Review. In review of contract with skilled nursing facility it was noted that the contract did not contain a provision which required all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. This was discussed with the administrator and corrected on-site with an addendum to the contract.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that for an LVN there was no documentation of a criminal background check. This was confirmed by the HR staff member and discussed with the administrator.