Every finding on record at Sunset Healthcare Services, Inc.

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) records reviewed, the agency did not ensure that the patient's individualized plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific needs of the patent. Clinical Record 1: Clinical Record 1: This patient was admitted to care on 08/24/2023 with a diagnosis of Dementia. On 08/31/2023 a phone communication from the patient documented the request for only nursing and medical director services. The updated plan of care 08/31/2023, 09/14/2023, and 09/28/2023 all included a frequency for chaplain and social worker of 1 month 1 and PRN visits. The PRN order lacked specificity on the criteria and the number of PRN visits. During interview 08/31/2023,

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 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 1 of 1 (100%) Records reviewed revealed that the individualized plans of care were not updated to reflect the changes in treatment. Clinical Record 1: Admitted on 08/24/2023 with end stage dementia. Nutritional concerns were identified. On 09/07/2023 Ensure was started as a supplemented and nursing visit note on 09/21/2023 continues to use ensure to supplement diet. The plan of care 09/14/2023 was not updated for the addition of ensure as a treatment for nutritional concerns. The plan of care 09/28/2023 was updated for ensure for nutrition. In an interview, the director of nursing stated the software creates multiple care plans each IDG meeting and the software has been contacted with this issue. She agreed that the 09/14/2023 plan did not get updated but that she was sure it was added to the 09/28/2023. The four different plans dated 09/28/2023 were all reviewed and one of the plans had the update.

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 CONDITION LEVEL DEFICIENCY This condition was not met as evidenced by a review of clinical records, agency policy, and interview of the leadership, which revealed the agency failed to obtain and include in the clinical records information from the physician for the registered nurse to be used when completing the comprehensive assessment [HCPC.11.I/L525/418.54(c)(1). noncompliance, 60%]; failed to ensure the initial bereavement assessments were completed [HCPC.13.I/L531/418.54(c)(7), noncompliance 60%]; failed to ensure the comprehensive assessment included a medication review [HCPC.15.I/L530/418.54(c)(6)(iii);noncompliance 80%]; and failed to ensure the plan of care reflected patient and family goals [HCPC.21.I/L545/.418.56(c). The cumulative effect of these deficiencies places the patient at risk for not having changes in their condition identified and their plan of care updated appropriately to meet their needs.

It is required that the comprehensive assessment includes consideration of the following factors: The nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints.\ This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed revealed the agency did not obtain and include in the clinical records information from the physician for the registered nurse to consider with objective and subjective data when completing the comprehensive assessment. Clinical Record 1: There was no documented evidence in the clinical record of a physician history and physical from the physician related to the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints for the registered nurse to consider when completing the comprehensive assessment dated 08/24/2023. Clinical Record 2: There was no documented evidence in the clinical record of a physician history and physical from the physician related to the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints for the registered nurse to consider when completing the comprehensive assessment dated 09/16/2022. Clinical Record 4: There was no documented evidence in the clinical record of a physician history and physical from the physician related to the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints for the registered nurse to consider when completing the comprehensive assessment dated 07/27/2022. The Administrator stated, "we don't always get a history and physical when we receive a referral."

It is required that the documented comprehensive assessment includes a drug profile that contains 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. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records review revealed the agency did not ensure that the comprehensive assessment included a medication review. Clinical Record 2: There was no documented evidence in the clinical record that the registered nurse comprehensive assessment dated 09/16/2022 included a review of the patient's prescription and over-the-counter medications. Clinical Record 3: The Physician history and physical dated 7/21/23 listed Doxycycline and Sulfa as medication allergies. The medication section for allergies on the registered nurse initial comprehensive assessment dated 07/25/2022 was blank. There was no documented evidence in the clinical record that the registered nurse comprehensive assessment dated 07/25/2022 included a review of the patient's prescription and over-the-counter medications. Clinical Record 4: There was no documented evidence in the clinical record that the registered nurse comprehensive assessment dated 07/27/2022 included a review of the patient's prescription and over-the-counter medications. Clinical Record 5: The Physician history and physical dated 10/05/2023 listed allergy as Celebrex. The allergy section on the registered nurse initial comprehensive assessment dated 10/05/2022 was blank. There was no documented evidence in the clinical record that the Registered Nurse comprehensive assessment dated 10/05/2022 included a review of the patient's prescription and over-the-counter medications. The Administrator reviewed the clinical records and stated, "we didn't document a comprehensive medication review for Record 2".

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, interview, and document review. 3 of 5 (60%) clinical records reviewed revealed that there was no documented evidence that the initial bereavement assessments were completed. Document 3: JCC013115 Hospice- CHAP Agency Bereavement Counseling Services, pages 1 of 5, states in part, " 1. Upon admission, a. Medical Social worker will complete no later than 5 days after the election of hospice care, an initial bereavement assessment. (i) If MSW services are declined, Spiritual Counseling Coordinators will perform. (ii) if MSW and Spiritual Counsel are declined, Registered Nurse (RN) will perform. Clinical Record 1: Patient Election of Benefit was dated 08/24/2023. The Medical Social was scheduled for 08/28/2023, but there was no documented evidence the visit was conducted. The chaplain performed a comprehensive assessment on 08/28/2023. There was no documented evidence that an initial bereavement risk assessment was completed as of 08/30/2023. Clinical Record 2: Patient Election of Benefit was dated 09/16/2022. The RN documented on the initial comprehensive assessment, Chaplain, Medical Social Worker and home health aide services were declined. There was no documented evidence that the RN conducted an initial bereavement assessment. Clinical Record 5: Patient Election of Benefit was dated 10/05/2022. There was no documented evidence that an initial risk assessment was completed by the Medical Social worker, chaplain or RN.s During an interview, the Administrator reviewed the clinical records and stated, "the initial bereavement assessments were not done."

It is required that each patient’s individualized written plan of care: reflects patient and family goals; This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed the agency did not ensure the plan of care reflected patient and family goals. Clinical Record 1: The Plan of Care dated 08/24/2023-11/21/2023 did not include documented evidence of patient and family goals. Clinical Record 2: The Plan of Care dated 09/16/2022-11/14/2022 did not include documented evidence of patient and family goals. Clinical Record 3: The Plan of Care dated 07/25/2022-10/22/2022 did not include documented evidence of patient and family goals. Clinical Record 4: The Plan of Care dated 07/27/2022-08/03/2022 did not include documented evidence of patient and family goals. Clinical Record 5: The Plan of Care dated 10/05/2022-10/26/2022 did not include documented evidence of patient and family goals. The Administrator was interviewed on 08/30/2023 and stated, "the plans of care do not include patient and family goals."

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records and interviews which revealed failure by the Governing Body and Administrator/Director Patient Care Services (DPCS) to ensure that the management and oversight of administrative and clinical operations of the hospice were occurring on a day-to-day basis, (HSLG.3.I/L651). The cumulative effect and scope of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

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, 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 record review, document review, and interviews, which revealed failure of the Governing Body to ensure that the Administrator/DON assumed responsibility for the day-to-day hospice operations and the delivery of hospice services. The Administrator failed to ensure that initial bereavement assessments were completed, that the comprehensive assessments included a medication review, the certifications of terminal illness were completed and contained in the clinical record, the recertification for terminal illness was completed within the cert period, and the clinical records were safeguarded against loss or unauthorized use. The Administrator retrieved a "thumb drive" from her home that contained the patient records and presented it to the surveyor to conduct the clinical record review. The thumb drive was not password protected or encrypted, and it contained several other files which the administrator stated were of a personal information. In (40%) clinical records reviewed, the agency did not ensure the record contained the patient's response to symptom management, treatments and services. During interviews with the Administrator revealed the following: (1)The Administrator had to call the medical director's office to get copies of the written certifications of terminal illnesses, for all the patients but the written certification for the second benefit for Record 3 was not provided. She stated, "this is what they sent me." (2)The Administrator was interviewed on 08/30/2023 and stated, " I will call the physician's office and have them send me a copy of the signed Certifications of Terminal Illness (CTs)." The Administrator presented signed copies of the CTIs she received from the physician's office after not being able to locate the CTIS in the clinical records, file cabinet, computer software program and file storage boxes. (3) The Administrator was interviewed on 08/30/2023 and stated, "I am going to start using the software program skilled nurse visit notes, since they contain the information that needs to be documented." (4) The Administrator reviewed the clinical records and stated, "we didn't document a comprehensive medication review for Record 2.

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 clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure that a written certification of terminal illness was completed. Clinical Record 3: The patient elected hospice on 07/25/2022. There was no documented evidence in the clinical record of a written certification for benefit period 10/23/2022-12/08/2022. The Administrator had to call the medical director's office to get copies of the written certifications of terminal illnesses, for all the patients but the written certification for the second benefit for Record 3 was not provided. She stated, "this is what they sent me."

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: 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; signed copies of the notice of patient rights and the hospice election statement; responses to medications, symptom management, treatments, and services; outcome measure data elements per regulation; physician certification and recertification of terminal illness as required; any advance directives; copies of the inpatient discharge summary, as applicable; and physician orders. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews of Agency management, which revealed the agency failed to ensure that entries in the patient record were legible, complete and appropriately authenticated. [HSIM.4.I/L679/418.104(b 100% noncompliance]; failed to ensure the record contained the patient's response to symptom management, treatments and services [HSIM.3.I/L674/418.04(a)(3) noncompliance 40%]; failed to ensure that physician certifications for terminal illness was contained in the clinical records [HSIM.3.I/L676/418.104(a)(5), noncompliance 80%]; failed to ensure ensure that a written and signed certification of terminal illness was completed within two (2) calendar days after the first day the benefit period, and no more than fifteen (15) days before the end of the first benefit period [HCPC.6.I/L676/418.104(a)(5), noncompliance 100%]; failed to ensure that clinical records, contents and the information was safeguarded against loss or unauthorized use [HSIM.5.I/L680/418.104(c), noncompliance 100%]; failed to ensure a discharge summary was sent to the physician when a patient revoked the hospice benefit, [HCDT.39.I/L683/418.104(e)(2)(i), noncompliance 100%]; and to ensure clinical records were readily available when requested by the site the surveyor.[HSIM.6.I/L685/ 418.104(f), noncompliance 100%]. The cumulative effect of these deficiencies could place the patient in jeopardy for a safety risk or lack of quality care.

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, responses to medications, symptom management, treatments, and services. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the record contained the patient's response to symptom management, treatments and services. Clinical Record 2: The patient elected hospice on 09/16/2022. There was no documented evidence in the clinical record for benefit period 09/16/2022-11/14/2022 for the patient's response to medications, symptom management and services. The plan of care dated 09/16/2022-11/14/2022 stated skilled nurse frequency was once a week. There was no documented evidence of a response to medications, symptom management and services.in the clinical record of skilled nurse visit notes dated 9/23/2022,09/30/2022, 10/7/2022,10/14/2022,10/21/2022, 10/28/2022,11/04/2022, and 11/11/2022. Clinical Record 3: The patient elected hospice on 07/25/2022. There was no documented evidence in the clinical record skilled nurse visit notes dated 08/04/2022, 08/11/2022, 08/18/2022, 08/25/2022, 09/01/2022, 09/08/2022, 09/15//2022, 09/22/2022 and 09/29/2022.09/16/2022-11/14/2022 of the patient's response to medications, symptom management and services. The Administrator was interviewed on 08/30/2023 and stated, "I am going to start using the software program skilled nurse visit notes, since they contain the information that needs to be documented."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 5 (80%) clinical records reviewed revealed the hospice did not ensure that physician certifications for terminal illness was contained in the clinical records. Document 5: Clinical Record Hospice Policy and Procedure Manual JCC0115 states in part, "Content (C) Each clinical record will include the following, as applicable to the scope of services provided by the hospice: 5. Certification of Terminal Illness." Clinical Record 2: The patient elected hospice on 09/16/2022. There was no documented evidence in the clinical record of the physician certification of terminal illness for benefit period 09/16/2022-11/14/2022. Clinical Record 3: The patient elected hospice on 07/25/2022. There was no documented evidence in the clinical record of the physician certification of terminal illness for benefit period 07/25/2022-10/22/2022 and 10/23/2022-12/08/2022. Clinical Record 4: The patient elected hospice on 07/27/2022. There was no documented evidence in the clinical record of the physician certification of terminal illness for benefit period 07/27/2022-08/03/2022. Clinical Record 5: The patient elected hospice on 10/05/2022. There was no documented evidence in the clinical record of the physician certification of terminal illness for benefit period 10/05/2022-10/26/2022. The Administrator was interviewed on 08/30/2023 and stated, " I will call the physician's office and have them send me a copy of the signed Certifications of Terminal Illness (CTs)." The Administrator presented signed copies of the CTIs she received from the physician's office after not being able to locate the CTIS in the clinical records, file cabinet, computer software program and file storage boxes.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure that entries in the patient record were legible, complete and appropriately authenticated. Document 5: Agency Policy, JCC013115 states in part, " B. The hospice will: 4. Ensure that entries are: b. Legible, clear, complete, current, accurate, and appropriately authenticated and dated by the person making the entry. C. Include title and credentials of the person making the entry." Clinical Record 1: The signature of the Registered Nurse (Staff 1) was not legible or complete on the witness section of the Informed Consent Admission to Hospice paper documents dated 08/24/2023 and there was no documented evidence of electronic forms for consents. Clinical Record 2: The signature of the Registered Nurse (Staff 1) was not legible or complete on the witness section of the Informed Consent Admission to Hospice paper documents dated 09/16/2022 and there was no documented evidence of electronic forms for consents. Clinical Record 3: The signature of the Registered Nurse (Staff 1) was not legible or complete on the witness section of the Informed Consent Admission to Hospice paper documents dated 07/25/2022 and there was no documented evidence of electronic forms for consents. Clinical Record 4: The signature of the Registered Nurse (Staff 1) was not legible or complete on the witness section of the Informed Consent Admission to Hospice paper documents dated 07/27/2022 and there was no documented evidence of electronic forms for consents. Clinical Record 5: The signature of the Registered Nurse (Staff 1) was not legible or complete on the witness section of the Informed Consent Admission to Hospice paper documents dated 10/05/2022 and there was no documented evidence of electronic forms for consents. The Administrator was interviewed on 08/30/2022 and stated, ""I am going to start using the software program so they will be readable."

It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use. The hospice addresses: leaving and protecting patient record information in the home, and prevention of physical or electronic altering of the patient record. The hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure that the clinical records, contents and the information was safeguarded against loss or unauthorized use. Document 1: Agency policy on Clinical records states in part, "3. Computerized records will meet all requirements of paper records, including protection from unofficial use and retention for the period. and 5. Ensure the clinical record, whether hard copy or in electronic form, will be made readily available upon request by an appropriate authority." Clinical Record 1: When site visitor requested access to the patient records after getting login credentials for the software program and seeing that records were not included in the software program, the Administrator stated, " the patient information/record is on a "thumb drive" that is at her home. " The ADM left the office to go get the thumb drive and returned to the office. Upon her return, she put the thumb drive into the computer CPU and pulled up patient information/visit notes/assessments/plans of care and begin printing out for site visitor. The thumb drive was not password protected or encrypted. There were several other files on the thumb drive, which she stated was personal information. Clinical Record 2: When site visitor requested access to the patient records after getting login credentials for the software program and seeing that records were not included in the software program, the Administrator stated, " the patient information/record is on a "thumb drive" that is at her home. " The ADM left the office to go get the thumb drive and returned to the office. Upon her return, she put the thumb drive into the computer CPU and pulled up patient information/visit notes/assessments/plans of care and begin printing out for site visitor. The thumb drive was not password protected or encrypted. There were several other files on the thumb drive, which she stated was personal information. Clinical Record 3: When site visitor requested access to the patient records after getting login credentials for the software program and seeing that records were not included in the software program, the Administrator stated, " the patient information/record is on a "thumb drive" that is at her home. " The ADM left the office to go get the thumb drive and returned to the office. Upon her return, she put the thumb drive into the computer CPU and pulled up patient information/visit notes/assessments/plans of care and begin printing out for site visitor. The thumb drive was not password protected or encrypted. There were several other files on the thumb drive, which she stated was personal information. Clinical Record 4: When site visitor requested access to the patient records after getting login credentials for the software program and seeing that records were not included in the software program, the Administrator stated, " the patient information/record is on a "thumb drive" that is at her home. " The ADM left the office to go get the thumb drive and returned to the office. Upon her return, she put the thumb drive into the computer CPU and pulled up patient information/visit notes/assessments/plans of care and begin printing out for site visitor. The thumb drive was not password protected or encrypted. There were several other files on the thumb drive, which she stated was personal information. Clinical Record 5: When site visitor requested access to the patient records after getting login credentials for the software program and seeing that records were not included in the software program, the Administrator stated, " the patient information/record is on a "thumb drive" that is at her home. " The ADM left the office to go get the thumb drive and returned to the office. Upon her return, she put the thumb drive into the computer CPU and pulled up patient information/visit notes/assessments/plans of care and begin printing out for site visitor. The thumb drive was not password protected or encrypted. There were several other files on the thumb drive, which she stated was personal information. When site visitor requested access to the patient records after getting login credentials for the software program and seeing that records were not included in the software program, the Administrator stated, " the patient information/record is on a "thumb drive" that is at her home. " The ADM left the office to go get the thumb drive and returned to the office. Upon her return, she put the thumb drive into the computer CPU and pulled up patient information/visit notes/assessments/plans of care and begin printing out for site visitor. The thumb drive was not password protected or encrypted. There were several other files on the thumb drive, which she stated was personal information. Document 5: Clinical Record Policy, JCC013115 states in part, " A. 2. The hospice will establish an area for and store the original active patient records at the hospice's place of business (parent hospice, branch office, or alternate delivery site) from which services are actually 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 This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed for live patients discharged, the agency did not ensure that a discharge summary was sent to the physician when a patient revoked the hospice benefit. Clinical Record 2: A discharge comprehensive assessment was dated 11/14/2022. There was no documented evidence that a discharge summary was sent to the physician. The reason for the discharge was a revocation for rehabilitation inpatient therapy. Clinical Record 3: A physician order dated 12/08/2022 stated, "Discharge Live-Reason: Patient transferred to another hospice. Comments: Above patient transferred to another hospice agency, stated she wants to transfer due to her daughter-in-law- works at that agency." There is no documented evidence that the discharge summary was sent to physician. Clinical Record 5: The patient was discharged from the agency on 10/26/2022. The reason for this revocation was to receive inpatient rehabilitation therapy. There was no documented evidence that a discharge summary was sent to the physician. The Administrator was interviewed on 08/30/2023 and stated, "there wasn't a discharge summary sent to the physician."

It is required that the patient clinical record, whether in hard copy or in electronic form, is made readily available on request by an appropriate authority. This standard was not met as evidenced by interview and observation. In 5 of 5 (100%) clinical records requested for clinical review revealed the agency did not ensure the records were readily available when requested by the site the surveyor. Records, 1, 2, 3, 4 and 5. When site visitor requested access to the patient records after getting login credentials for the software program and seeing that records were not included in the software program, the Administrator stated, "the patient information/record is on a "thumb drive" that is at my home. " The Administrator left the office to go get the thumb drive and returned to the office. Upon her return, she put the thumb drive into the computer CPU and pulled up patient information/visit notes/assessments/plans of care and begin printing out for site visitor. The thumb drive was not password protected or encrypted. There were records several other files on the thumb drive, which she stated was personal information418.104(f) . Records, 1, 2, 3, 4 and 5. When site visitor requested access to the patient records after getting login credentials for the software program and seeing that records were not included in the software program, the Administrator stated, " the patient information/record is on a "thumb drive" that is at my home. " The ADM left the office to go get the thumb drive and returned to the office. Upon her return, she put the thumb drive into the computer CPU and pulled up patient information/visit notes/assessments/plans of care and begin printing out for site visitor. The thumb drive was not password protected or encrypted. There wereRecords several other files on the thumb drive, which she stated was personal information.