Every finding on record at Tender Care Hospice, LLC

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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a completed initial bereavement assessment. Clinical Record 1: The patient elected hospice services on 05/12/2023. A clinical record review revealed no evidence of a completed initial bereavement assessment as part of the comprehensive assessment. Clinical Record 2: The patient elected hospice services on 05/05/2023. A clinical record review revealed no evidence of a completed initial bereavement assessment as part of the comprehensive assessment. Clinical Record 3: The patient elected hospice services on 07/19/2024. A clinical record review revealed no evidence of a completed initial bereavement assessment as part of the comprehensive assessment. Clinical Record 4: The patient elected hospice services on 07/25/2024. A clinical record review revealed no evidence of a completed initial bereavement assessment as part of the comprehensive assessment. The Administrator, Director of Patient Care Services, and Regional Vice President of Operations stated in an interview on 08/22/2024 that the agency did not ensure the comprehensive assessment included a completed initial bereavement assessment.

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. CONTINUATION OF REQUIRED ACTION. 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 plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The patient elected hospice care on 07/19/2024 with a diagnosis of cerebrovascular disease, unspecified. The initial assessment completed by the Registered Nurse (RN) dated 07/19/2024 documented, “This patient struggles with dysphagia and requires a mechanical soft textured diet.” The POC dated 08/13/2024 did not include documentation of goal(s) and intervention(s) addressing the dysphagia. Clinical Record 4: The patient elected hospice care on 07/25/2024 with a diagnosis of chronic obstructive pulmonary disease, unspecified. The initial assessment completed by the RN dated 07/25/2024 documented “Nutrition: Dysphagia - YES.” The POC dated 07/25/2024 did not include documentation of goal(s) and intervention(s) addressing the dysphagia. During an interview on 08/22/2024, the Administrator, Director of Patient Care Services, and Regional Director confirmed that the POC did not include patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. CONTINUATION OF REQUIRED ACTION

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 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the patient's initial comprehensive assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 4: The patient elected hospice care on 06/07/2024 with the diagnosis of heart failure. The Registered Nurse (RN) initial assessment was completed on 06/07/2024, and the Chaplain assessment was completed on 06/11/2024. The social work assessment was completed on 06/24/2024, 17 days after the patient's election of hospice care. A clinical record review revealed no documented missed visit or coordination note explaining the psychosocial assessment delay. Clinical Record 7: The patient elected hospice care on 06/13/2024 with the diagnoses: cerebral arthrosis and diabetes. The POC dated 06/13/2024 ordered a Chaplain "1M1." As of 07/11/2024, there was no evidence of a Chaplain visit or spiritual assessment. A clinical record review revealed no documented reason for the delay in the spiritual assessment. Clinical Record 8: The patient elected hospice care on 01/23/2024 with the diagnoses: Alzheimer’s Disease and seizures. The Registered Nurse (RN) initial assessment was completed on 01/23/2024, and the Chaplain initial assessment was completed on 01/26/2024. The plan of care dated 01/23/2024 ordered the MSW “1M1.” A clinical record review revealed that no MSW visit or psychosocial assessment was completed. There was no documentation to explain why the psychosocial assessment and MSW visit were not completed. Clinical Record 10: The patient elected hospice care on 08/26/2023. The RN initial assessment was completed on 08/26/2023. The plan of care dated 08/26/2023 through 10/24/2023 ordered the MSW "1M1." The MSW visit and psychosocial assessment were completed on 10/18/2023. There was no documentation to explain the reason the psychosocial assessment was completed later than five (5) calendar days after the patient's election of hospice care. Clinical Record 12: The patient elected hospice care on 02/16/2024 with the diagnoses: chronic obstructive pulmonary disease (COPD) and a recent pleural effusion. The plan of care dated 02/16/2024 ordered MSW "1M1." A clinical record review revealed that no MSW visit or psychosocial assessment was completed. There was no documentation to explain why the psychosocial assessment and MSW visit were not completed. In a review and interview on 07/11/2024, the Director of Clinical Services confirmed the findings and that there was no documentation to explain delays.

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s comprehensive assessment identified the patient’s physical needs. Clinical Record 14: The patient elected hospice care on 03/28/2024. The Registered Nurse (RN) assessment dated 03/28/2024, documented the patient's several recent falls with injury, some requiring sutures. The wound section of the assessment indicated that the patient had an active wound, but no wound assessment or documentation identified the location of the wound. Following a joint record review and interviews on 07/11/2024, the DCS confirmed that the RN assessments were incomplete and lacked patient-specific wound or nutritional assessments.

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 following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] 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 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a medication profile that contained the patient's current medications. Clinical Record 2/Home Visit 2: The patient elected hospice care on 05/22/2024 and resided in a skilled nursing facility (SNF). A physician's order for “Citalopram 10 mg tablet” was received on 06/27/2024. Citalopram was added to the medication profile on 07/01/2024. During the home visit on 07/10/2024, a review of the patient's SNF medication administration record (MAR) revealed that the SNF did not have the order for Citalopram on the MAR. Clinical Record 3/Home Visit 3: The patient elected hospice care on 09/20/2023 with a diagnosis of heart failure. The plans of care for the benefit periods dated 04/17/2024 through 06/15/2024 and 06/16/2024 through 08/14/2024 ordered: "Oxygen 2.5 liters (L) continuous." The Registered Nurse (RN) recertification assessment dated 06/03/2024 documented that the patient was using "oxygen 3L per nasal cannula (NC) continuously." The skilled nurse (SN) visit notes dated 07/01/2024, 07/03/2024, and 07/08/2024 documented that the patient was using "oxygen 3L per NC continuously." The clinical record did not contain an order for "oxygen 3L per NC continuously." The medication profile was not updated and documented, "Oxygen 2.5 liters continuous." Clinical Record 4/Home Visit 4: The patient elected hospice care on 06/07/2024 with the diagnosis of heart failure. The Registered Nurse (RN) assessment dated 06/07/2024 documented that the patient used "Oxygen 3 liters (L) per NC occasionally during the day and continuously at night." During the home visit with the Social Worker (SW) [Personnel Record 4] on 07/10/2024, the patient was observed as extremely short of breath after answering the door and using oxygen for recovery. The medication profile did not document oxygen. Clinical Record 6: The patient elected hospice care on 06/25/2024 with the diagnoses: unspecified sequelae of cerebral infarction, aphasia, and type 2 diabetes mellitus. The patient resided in a skilled nursing facility (SNF). The phone interview with the SNF Assistant Director of Nursing on 07/11/2024, with the hospice Director of Clinical Services present, included a medication reconciliation and review. The hospice plan of care and medication profile did not include the complete list of medications provided at the facility. The following medications were documented on the SNF medication administration record (MAR) but not documented on the hospice medication profile or orders: Tramadol 1 tab every 6 hours PRN, L-Arginine 1 tab, two times a day, zinc 50 mg daily, sodium chloride 1 gm three times a day, vitamin C 100mg daily, Glucerna 135 ml 4 times a day over 1 hour with water flushes, flush Banatrol Plus Banana flakes twice daily via percutaneous endoscopic gastrostomy (PEG) tube, and flush unflavored Juven BID for wound healing, 1 packet in warm water, flush before and after the Juven. The Director of Clinical Services confirmed that the medications identified as active at the SNF were not included on the hospice medication profile. Clinical Record 13: The patient elected hospice care on 01/29/2024 with the diagnoses of heart failure, cerebral vascular accidents (CVA), and transient ischemic attacks (TIA). The patient resided in an adult living facility (ALF). The Registered Nurse (RN) initial assessment at the start of care on 01/29/2024 documented that the patient was extremely short of breath and required "oxygen of 3.5 L per NC continuous." The medication profile did not include the oxygen liter flow and frequency of administration until 07/03/2024, when it was added to the medication profile as "2 L daily." The medication profile did not document if the oxygen administration was continuous or as needed (PRN). The patient was using "oxygen of 3.5 L per NC continuous." Following a joint clinical record review on 07/11/2023, the Director of Clinical Services confirmed the findings of incomplete drug profiles.

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 a review of clinical records and interviews with the Vice President (VP) of Operations, Administrator, and Director of Clinical Services, which revealed the hospice: Failed to ensure that the Registered Nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care in 1 of 19 (5%) clinical records reviewed [HCPC.19.I/L540]; Failed to ensure an individualized written plan of care was prepared for each patient based on the comprehensive assessment in 4 of 19 (21%) clinical records reviewed [HCPC.21.I/L545]; Failed to ensure that the patient's care and services followed the plan of care established by the hospice interdisciplinary group in 2 of 19 (10%) clinical records reviewed [HCPC.19.I/L543]; Failed to ensure all drugs and treatments necessary to meet the patient's needs were included in the plan of care in 5 of 19 (26%) clinical records reviewed [HCPC.21.I/L549]; and Failed to ensure that hospice care and services followed the patient's plan of care in 2 of 19 (12%) clinical records reviewed [HCPC.21.I/L550]. 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 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met, as evidenced by clinical record review, interview, and observation. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the RN coordinated care, continuously assessed, and implemented the plan of care to meet the patient's needs. Clinical Record 6: The patient elected hospice care on 06/25/2024 with the diagnoses: of unspecified sequelae of cerebral infarction, aphasia, and type 2 diabetes. The nutritional assessment section of the RN assessment dated 06/25/2024 documented, "patient eats 90-100% of meals or has a feeding tube." There was no other documentation identifying if the patient was (nothing by mouth) NPO or could take input by mouth. During a phone interview with the RN on 07/10/2024, the RN confirmed that the patient had a feeding tube and stated, "The facility is managing the feeding tube." A phone interview with the skilled nursing facility (SNF) Assistant Director of Nursing on 07/11/2024, with the hospice Director of Clinical Services (DCS) present, revealed that the patient had a percutaneous endoscopic gastrostomy (PEG) tube in place for supplemental feeding and medications were taken by mouth. The hospice plan of care and medication profile did not include documentation of the medications provided at the SNF. The following medications were documented on the patient's SNF medication administration record (MAR) but not on the hospice medication profile or plan of care: Tramadol 1 tab every 6 hours PRN, L-Arginine 1 tab, two times a day, zinc 50 mg daily, sodium chloride 1 gm, three times a day, Vitamin C 100mg daily, Glucerna 135 ml 4 times a day over 1 hour with water flushes. Flush Banatrol Plus Banana flakes twice daily via peg tube. Flush unflavored Juven BID for wound healing, (1) one packet in warm water, flush before and after Juven. The Director of Clinical Services (DCS) confirmed that the medications and tube feedings identified as active at the SNF were not included in the hospice medication profile and plan of care. The DCS confirmed the findings after a joint review of the clinical record and interviews on 07/11/2024.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative if any of them so desire; [and] the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (10%) clinical records reviewed, the agency did not ensure that hospice care and services followed the patient's plan of care. Clinical Record 11: The patient elected hospice care on 01/23/2024 with the diagnoses: Alzheimer's Disease and diabetes mellitus. The patient resided at home. For the benefit period dated 04/22/2024 through 07/20/2022, the POC ordered skilled nursing (SN) services "2wk13" and "4 as needed/pro re nata (PRN) for symptom management." A clinical record review revealed that as of 07/11/2024, the last SN visit note was documented on 06/24/2024. The SN completed missed visit notes on 07/06/2024 for the visits scheduled for 06/27/2024 with the reason documented as "on vacation" and 07/02/2024 with the reason documented as "Pt. no response to text." There was no documentation for the second missed visit for the week of 06/30/2024. During a joint record review and interview on 07/11/2024, the Vice President (VP) of Operations, Administrator, and Director of Clinical Services confirmed that the nurse had documented as "on vacation" for a missed visit reason, which was inconsistent with the agency's expectations. Clinical Record 12: The patient elected hospice care on 02/16/2024 with the diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided at home. For the benefit period dated 06/15/2024 through 08/13/2024, the plan of care (POC) ordered Medical Social Worker (MSW) services: "effective 06/15/2024 1M1, 2M1, 1M1." A clinical record review revealed no MSW visits from 06/15/2024 through 07/11/2024. The MSW completed a missed visit coordination note on 06/30/2024 that documented "MSW unable to visit." There was no indication that the patient was unavailable for a visit. During a joint record review and interview on 07/11/2024, the Vice President (VP) of Operations, Administrator, and Director of Clinical Services, the VP of Operations, confirmed that the plan of care was not followed and care was not provided as ordered.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient's plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 06/04/2024 with the diagnosis of chronic respiratory failure with hypoxia. The patient resided at home. The skilled nurse (SN) assessment dated 06/04/2024 documented that the patient smoked, was prescribed continuous oxygen and was on blood thinners following a recent hospitalization for a blood clot. The plan of care identified oxygen precautions under safety measures but did not document patient-specific interventions or safety measures related to the patient's continued smoking and use of oxygen. The SN assessment dated 06/04/2024 documented that the patient was using blood thinners and was recently hospitalized for a blood clot. The plan of care safety measures documented bleeding precautions and seizure precautions. No anticoagulants were ordered on the plan of care, and the POC and SN assessment did not document a diagnosis or history of seizures. The plan of care section labeled durable medical equipment (DME) and supplies documented prothrombin time/international normalized ratio (PT/INR) supplies. The plan of care did not document physician orders or interventions regarding the PT/INR. Wound care supplies were documented in the plan of care. However, no wound care interventions were ordered, and the skilled nursing assessment did not identify that the patient had wounds. The skilled nurse assessment on 06/04/2024 documented "food and nutritional resources and services needed - dietician." Food and nutritional resources were not addressed in the plan of care, and no dietician was ordered. During an interview on 07/10/2024, the Director of Clinical Services (DCS) confirmed the deficiencies in the plan of care. Clinical Record 3: The patient elected hospice care on 09/20/2023 with a diagnosis of heart failure. The interventions were not updated and included in the recertification plan of care dated 06/16/2024 through 08/14/2024. In an interview with the Director of Clinical Services (DCS) and corporate staff on 07/10/2024, they confirmed that the interventions had not been updated and included. Clinical Record 5: The patient elected hospice care on 02/23/2024 with the diagnoses: hypertensive heart, hypertension (HTN), and chronic pain. The interventions were not updated and included in the recertification plan of care dated 05/23/2024 through 08/20/2024. In an interview with corporate support and the director of clinical services on 07/11/2024, they confirmed that the interventions had not been updated and included. Clinical Record 10: The patient elected hospice care on 08/26/2023 with the diagnoses: atherosclerotic heart disease heart failure. The interventions were not updated and included in the recertification plan of care dated 06/21/2024 through 08/19/2024. In an interview with the Director of Clinical Services (DCS) and corporate staff on 07/10/2024, they confirmed that the interventions had not been updated and included.

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 clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the patient's plan of care included the drugs and treatments necessary to meet the patient's needs. Clinical Record 6: The patient elected hospice care on 06/25/2024 with the diagnoses: unspecified sequelae of cerebral infarction, aphasia, and type 2 diabetes mellitus. The patient resided in a skilled nursing facility (SNF). The phone interview with the SNF Assistant Director of Nursing on 07/11/2024, with the hospice Director of Clinical Services present, included a medication reconciliation and review. The hospice plan of care and medication profile did not include the complete list of medications being provided at the facility. The following medications were documented on the SNF medication administration record (MAR) but not documented on the hospice medication profile or orders: Tramadol 1 tab every 6 hours PRN, L-Arginine 1 tab two times a day, zinc 50 mg daily, sodium chloride 1 gm three times a day, vitamin C 100mg daily, Glucerna 135 ml 4 times a day over 1 hour with water flushes, flush Banatrol Plus Banana flakes twice daily via percutaneous endoscopic gastrostomy (PEG) tube, and flush unflavored Juven BID for wound healing, 1 packet in warm water, flush before and after the Juven. The Director of Clinical Services confirmed that the medications identified as active at the SNF were not included in the plan of care. The Registered Nurse (RN) initial assessment dated 06/25/2024 documented that the patient had an "indwelling/suprapubic catheter" and was "eating 100% of meals or on a tube feeding." The plan of care dated 06/25/2024 ordered: "Skilled nurse (SN) for administration of catheter insertion/maintenance and skilled nurse to provide instruction on management of catheter." A clinical record and plan of care review revealed no orders specifying the catheter type and size and no orders for changing and maintaining the catheter. The plan of care documented the intervention "Need for nasogastric tube insertion/removal and intervention," but did not include documentation of the solution, amount, or frequency of the tube feedings. An interview with the SNF staff revealed that the patient had a PEG tube and was receiving tube feedings three (3) times a day. The SNF staff confirmed that the patient never had a nasogastric tube. Clinical Record 9: The patient elected hospice care on 05/12/2023 with the diagnoses: Alzheimer's Disease and a wound. The SN assessment dated 06/24/2024 documented that the patient had a stasis ulcer. The SN visit note dated 07/09/2024 documented that the stasis ulcer remained a problem. The plan of care for the benefit period dated 07/05/2024 through 09/02/2024 did not document interventions for wound care. The plan of care documented discipline orders with frequency, medications, and goals but did not include interventions. Clinical Record 12: The patient elected hospice care on 02/16/2024 with the diagnoses: chronic obstructive pulmonary disease (COPD) and a recent pleural effusion. The verbal order dated 02/20/2024 ordered: "oxygen 2L -5 L per NC as needed." The SN recertification assessment dated 06/04/2024 documented that the patient was using oxygen continuously. The medication profile included documentation of medications from 02/20/2024. The plan of care for the benefit period dated 06/15/2024 through 08/13/2024 did not document orders or interventions for oxygen. Clinical Record 13: The patient elected hospice care on 01/29/2024 with the diagnoses of heart failure, cerebral vascular accidents (CVA), and transient ischemic attacks (TIA). The patient resided in an adult living facility (ALF). The Registered Nurse (RN) initial assessment at the start of care on 01/29/2024 documented that the patient was extremely short of breath and required "oxygen of 3.5 liters (L) per nasal cannula (NC) continuous." A clinical record review revealed that the patient had been on continuous oxygen at 3 L- 3.5 L since admission on 01/29/2024. The plan of care dated 05/28/2024 through 07/26/2024 did not document oxygen or interventions addressing the patient's use of oxygen. Clinical Record 14: The patient elected hospice care on 03/28/2024 with the diagnoses: Parkinson's and falls. The plan of care for the benefit period dated 03/28/2024 read in part, "Skilled nurse to perform, instruct /reinforce to patient /caregiver wound care to closed incision /suture line daily as ordered. Cleanse with antibacterial soap and water. If oozing, cover with dry gauze and tape securely using clean technique." There was no documentation to identify where on the patient's body the wound was located. The plan of care for the benefit period dated 06/26/2024 through 09/23/2024 did not document 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: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (12%) clinical records reviewed, the agency did not ensure that the patient's plan of care included the medical supplies and appliances necessary to meet the patient's needs. Clinical Record 4/Home Visit 4: The patient elected hospice care on 06/07/2024 with the diagnosis of heart failure. The Registered Nurse (RN) assessment dated 06/07/2024 documented that the patient used "Oxygen 3 liters (L) per NC occasionally during the day and continuously at night." During the home visit with the Social Worker (SW) [Personnel Record 4] on 07/10/2024, the patient was observed as extremely short of breath after answering the door and using oxygen for recovery. The plan of care dated 06/07/2024 read "self-care" under the section labeled “DME and Supplies” and did not include oxygen. Clinical Record 6: The patient elected hospice care on 06/25/2024 with the diagnoses: unspecified sequelae of cerebral infarction, aphasia, and type 2 diabetes mellitus. The patient resided in a skilled nursing facility (SNF). The phone interview with the SNF Assistant Director of Nursing on 07/11/2024, with the hospice Director of Clinical Services present, revealed that the patient had a percutaneous endoscopic gastrostomy (PEG) tube in place and a Foley catheter. The plan of care dated 06/25/2024 did not include the Foley catheter supplies or PEG tube feeding supplies. Following a joint record review on 07/10/202424, the Director of Clinical Services confirmed that the required DME/supplies were not included in the plan of care.

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 CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record reviews, personnel record reviews, and interviews with the Regional Vice President of Operations, Administrator, and Director of Clinical Services which revealed the following: Failure of the hospice to ensure that the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for the supervision of the Hospice Aide in 3 of 14 (21%) clinical records reviewed [HCDT.15.I/L625]; Failure of the hospice to ensure that the Hospice Aide provided visits as ordered by the Interdisciplinary group in 1 of 14 (7%) clinical records reviewed [HCDT.16.I/L626]; Failure of the hospice to ensure that the Hospice Aide provided services as instructed in the Hospice Aide care plan in 1 of 14 (7%) clinical records reviewed [HCDT.16.I/L626]; Failure of the hospice to ensure that the Hospice Aide reported changes in the patient's needs to the RN in 2 of 14 (14%) clinical records reviewed [HCDT.16.I/L628]; and Failure of the hospice to ensure that an annual on-site visit to the location where a patient is receiving care was completed to assess and observe the HA performing patient care in 1 of 1 (100%) personnel record reviewed [HSRM.27.D/L632]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the HA received written patient care instructions. Clinical Record 1: The patient elected hospice care on 06/04/2024 with the diagnosis of chronic respiratory failure with hypoxia. The patient resided at home. The skilled nurse (SN) assessment dated 06/04/2024 documented that the patient smoked and was prescribed continuous oxygen. The HA care plan documented fall precautions. The HA care plan did not include oxygen precautions or provide the HA with oxygen and smoking safety instructions. Clinical Record 5: The patient elected hospice care on 02/23/2024 with the diagnoses: hypertensive heart, hypertension (HTN), and chronic pain. The HA aide care plan updated on 03/09/2024 by the Registered Nurse (RN), assigned the HA the relevant tasks: bathing (shower) every visit, hair care, lotion, nail care, oral care, and perineal care every visit, stand-by assistance with ambulation, transferring the client from bed to chair, and transferring client from chair to bed every visit. The verbal order dated 05/21/2024 documented that the patient had a "wound on her chin with a dressing to be changed two times a week." On 06/28/2024, the physician ordered dressing changes three (3) times weekly for the stage 2 pressure ulcer on the patient's right foot. The HA care plan was not updated, and the HA was not provided with directions on managing dressings while providing the ordered shower. Clinical Record 6: The patient elected hospice care on 06/25/2024 with the diagnoses: unspecified sequelae of cerebral infarction, aphasia, and type 2 diabetes mellitus. The patient resided in a skilled nursing facility (SNF). During an interview on 07/11/2024, the SNF Assistant Director of Nursing, with the hospice Director of Clinical Services present, confirmed that the patient had a percutaneous endoscopic gastrostomy tube (PEG) tube in place. The HA care plan dated 06/25/2024 did not document the patient had a PEG tube in place or provide any direction to the HA related to the patient's ability to take food and fluids by mouth.

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review. In 1 of 14 (7%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 5: The patient elected hospice care on 02/23/2024 with the diagnoses: hypertensive heart, hypertension (HTN), and chronic pain. The patient resided in an adult living facility (ALF). The HA aide care plan, updated by the Registered Nurse (RN) on 03/09/2024, assigned the HA the relevant tasks: bathing (shower) every visit, hair care, lotion, nail care, oral care, and perineal care every visit, stand-by assistance with ambulation, transferring the client from bed to chair, and transferring client from chair to bed every visit. The HA visit note dated 06/05/2024 documented that the patient refused the shower, hair care, oral care, nail care, and lotion. The HA visit notes dated 06/12/2024 and 06/19/2024 documented "patient unable" for the task standby assist and refused nail care and oral care. The HA visit note dated 07/01/2024 documented that the patient refused a shower, assist to toilet, oral care, and nail care. A clinical record review revealed no documentation indicating a change in the care plan or that the RN was notified of the patient's refusal of services.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the HA reported changes in patient's needs to the Registered Nurse (RN). Clinical Record 5: The patient elected hospice care on 02/23/2024 with the diagnoses: hypertensive heart, hypertension (HTN), and chronic pain. The patient resided in an adult living facility (ALF). The HA aide care plan, updated by the Registered Nurse (RN) on 03/09/2024, assigned the HA the relevant tasks: bathing (shower) every visit, hair care, lotion, nail care, oral care, and perineal care every visit, stand-by assistance with ambulation, transferring the client from bed to chair, and transferring client from chair to bed every visit. The HA visit note dated 06/05/2024 documented that the patient refused the shower, hair care, oral care, nail care, and lotion. The HA visit notes dated 06/12/2024 and 06/19/2024 documented "patient unable" for the task standby assist and refused nail care and oral care. The HA visit note dated 07/01/2024 documented that the patient refused a shower, assist to toilet, oral care, and nail care. A clinical record review revealed no documentation indicating the HA notified the RN that the patient refused the assigned tasks. Clinical Record 11: The patient elected hospice care on 01/23/2024 with the diagnoses: Alzheimer's Disease and diabetes mellitus. The patient resided at home. For the benefit period dated 04/22/2024 through 07/20/2024, the skilled nurse (SN) visit note dated 06/24/2024 documented that the patient had "zero pain." The HA visit notes dated 06/24/2024, 06/28/2024, 07/01/2024, 07/05/2024, and 07/08/2024 documented that the patient complained of left shoulder pain. A clinical record review revealed no documentation indicating the HA notified the RN of the patient's left shoulder pain. A clinical record review revealed no SN visits or assessments from 06/24/2024 through 07/11/2024. During an interview on 07/10/2024, the Director of Clinical Services confirmed that the clinical records contained no evidence of the HA notifying the RN of changes in the patient's condition and needs.

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met, as evidenced by clinical record review and interview. In 1 of 1 (100%) personnel record review of a Hospice Aide (HA) hired more than twelve months ago, the agency did not ensure that an annual on-site visit to the location where a patient is receiving care was completed to assess and observe the HA performing patient care. Personnel Record 9: The Hospice Aide was hired on 04/03/2023. A review of the personnel record revealed no evidence of an annual on-site visit. During the joint review of the personnel record, the Administrator reported that the agency completes an annual skills check on a mannequin. After reviewing the standard, the Administrator voiced understanding and confirmed that the agency has not completed annual on-site reviews of the Hospice Aide. In an interview on 07/10/2024, the Administrator stated, "I didn't realize that was a regulation. We have an annual skills day with a mannequin, and I thought that met the requirement.”

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. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient's clinical record included physician orders for all treatments and medications. Clinical Record 3/Home Visit 3: The patient elected hospice care on 09/20/2023 with a diagnosis of heart failure. The plans of care for the benefit periods dated 04/17/2024 through 06/15/2024 and 06/16/2024 through 08/14/2024 ordered: "Oxygen 2.5 liters (L) continuous." The Registered Nurse (RN) recertification assessment dated 06/03/2024 documented that the patient was using "oxygen 3L per nasal cannula (NC) continuously." The skilled nurse (SN) visit notes dated 07/01/2024, 07/03/2024, and 07/08/2024 documented that the patient was using "oxygen 3L per NC continuously." The clinical record did not contain an order for "oxygen 3L per NC continuously." Clinical Record 4/Home Visit 4: The patient elected hospice care on 06/07/2024 with the diagnosis of heart failure. The Registered Nurse (RN) assessment dated 06/07/2024 documented that the patient used "Oxygen 3 liters (L) per NC occasionally during the day and continuously at night." During the home visit with the Social Worker (SW) [Personnel Record 4] on 07/10/2024, the patient was observed as extremely short of breath after answering the door and using oxygen for recovery. The plan of care dated 06/07/2024 through 09/04/2024 did not document oxygen. A clinical record review revealed no orders for oxygen. During a joint record review, the Administrator confirmed no oxygen orders. Clinical Record 13: The patient elected hospice care on 01/29/2024 with the diagnoses: heart failure, cerebral vascular accidents (CVA), and transient ischemic attacks (TIA). The patient resided in an adult living facility (ALF). The Registered Nurse (RN) initial assessment at the start of care on 01/29/2024 documented that the patient was extremely short of breath and required "oxygen of 3.5 L per NC continuous." Orders for the oxygen liter flow and frequency of administration were not included in the plan of care. During an interview on 07/11/2024, the Director of Clinical Services confirmed that the clinical records did not include the required orders.

It is required that a hospice providing hospice care to residents of a SNF/NF or an ICF/IDF follows the standards defined elsewhere in this Manual and those that follow. THIS IS A CMS CONDITION-LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, observation, and interview with the Administrator, Regional Vice President of Operations, and Director of Clinical Services which revealed that the hospice failed to assume responsibility for the professional management of the SNF patIent's hospice services in accordance with the hospice plan of care (POC) in 5 of 5 (100%) clinical records reviewed of patients who resided in a SNF [HSRF.3.I/L762]; Failed to ensure that the patient's plan of care identified the care and services needed, and specified which provider was responsible for performing the functions in 5 of 5 (100%) clinical records reviewed of patients who resided in a SNF [HSRF.6.I/L774]; Failed to ensure that the IDG member provided the SNF with the patient's physician certification and recertification of the terminal illness in 2 of 2 (100%) home visits observed of patients residing in a SNF [HSRF.9.I/L781]; and Failed to ensure that the SNF received each patient’s most recent hospice plan of care in 2 of 2 (100%) home visits observed of patients residing in a SNF [HSRF.9.I/L781]. The cumulative effect of these systemic problems has resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR 484.112: Hospices that provide hospice care to residents of a SNF/NF or ICF/IID. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients residing in a skilled facility cared for by the agency.

It is required that the hospice assumes responsibility for the professional management of the SNF/NF or ICF/IDF resident's hospice services in accordance with the hospice plan of care (POC) and the hospice conditions of participation. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed of patients who resided in a skilled nursing facility (SNF), the agency did not ensure that the hospice assumed responsibility for the professional management of the SNF patient's hospice services in accordance with the hospice plan of care (POC). Clinical Record 2/Home Visit 2: The patient elected hospice care on 05/22/2024 and resided in a skilled nursing facility (SNF). The hospice plan of care dated 5/22/2024 through 08/19/2024 ordered, "hospice nurse to instruct patient/caregiver on use of pain medications, hospice nurse for observation and assessment of patient safety, hospice nurse to observe/assess nutrition and hydration status, and hospice nurse of observation /assessment of effectiveness of symptom relief measures including oxygen." The hospice plan of care did not identify which provider was responsible for performing the functions included in the plan of care. During an interview, the SNF nurse reported that the SNF received a medication list from the hospice, and there was not much other collaboration. The SNF medical records clerk reported that they searched through unscanned documents but had no evidence of the certification of terminal illness CTI. The SNF did not have copies of the hospice plan of care. Clinical Record 3/ Home Visit 3: The patient elected hospice care on 09/20/2023 and resided in a SNF. During the home visit with the RN [Personnel Record 2] on 07/10/2024, a review of the patient's SNF medical record revealed that the most recent Interdisciplinary Group (IDG) plan of care update report was dated 04/25/2024. The hospice plan of care for the benefit period dated 04/17/2024 through 06/15/2024 did not identify which provider was responsible for performing the functions included in the plan of care. A review of the patient's SNF medical record revealed that the CTI received by the SNF expired on 12/18/2023 and that the most recent Interdisciplinary Group (IDG) plan of care update report was dated 04/25/2024. The SNF did not have the hospice plan of care for the benefit period dated 06/16/2024 through 08/14/2024. The hospice RN asked the SNF office staff to confirm that there was no current plan of care. The SNF office staff stated in part, "We always have a hard time getting the documents that we need from hospices." Clinical Record 6: The patient elected hospice care on 06/25/2024 with the diagnoses: unspecified sequelae of cerebral infarction, aphasia, and type 2 diabetes mellitus. The plan of care ordered: "skilled nurse for administration of catheter insertion/maintenance, skilled nurse to provide instruction on management of catheter, need for nasogastric tube insertion/removal and intervention." During an interview on 07/10/2024, the patient's hospice RN [Personnel Record 2] confirmed that the patient had a percutaneous endoscopic gastrostomy (PEG) tube, not a nasogastric tube. In addition, the plan of care ordered, "Skilled nurse (SN) for administration of catheter insertion/maintenance and skilled nurse to provide instruction on management of catheter." There was no mention of a peg tube on the plan of care. The hospice plan of care did not identify which provider was responsible for performing the functions included in the plan of care. During an interview, the SNF staff reported that the patient had a PEG tube that the SNF managed. Clinical Record 9: The patient elected hospice care on 05/12/2023 with the diagnoses: Alzheimer's Disease and a stasis ulcer. The initial assessment on 05/12/2023 documented that the patient had a stasis ulcer. The SN assessments dated 06/24/2024 and 07/09/2024 documented that the patient had a stasis ulcer, which continued to be a problem. The hospice plan of care for the benefit period dated 07/05/2024 through 09/02/2024 did not identify which provider was responsible for performing the functions included in the plan of care. Clinical Record 16: The patient elected hospice care on 04/13/2024 with the diagnosis of heart failure. The patient resided in SNF. The hospice plan of care dated 04/13/2024 through 07/11/2024 did not identify which provider was responsible for performing the functions included in the plan of care. Following the joint record review on 07/102024, the Administrator, Regional Vice President of Operations, and Director of Clinical Services confirmed that the plans of care did not include evidence of consultation and collaboration with the SNF and did not specify who was responsible for the interventions.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed of patients who resided in a skilled nursing facility, the agency did not ensure that the patient's plan of care identified the needed care and services, and specified which provider was responsible for performing the functions. Clinical Record 6: The patient elected hospice care on 06/25/2024 with the diagnoses: unspecified sequelae of cerebral infarction, aphasia, and type 2 diabetes mellitus. The plan of care ordered: "skilled nurse for administration of catheter insertion/maintenance, skilled nurse to provide instruction on management of catheter, need for nasogastric tube insertion/removal and intervention." During an interview on 07/10/2024, the patient's hospice RN [Personnel Record 2] confirmed that the patient had a percutaneous endoscopic gastrostomy (PEG) tube, not a nasogastric tube. In addition, the plan of care ordered, "Skilled nurse (SN) for administration of catheter insertion/maintenance and skilled nurse to provide instruction on management of catheter." There was no mention of a PEG tube on the plan of care. The hospice plan of care did not identify which provider was responsible for performing the functions included in the plan of care. During an interview, the SNF staff reported that the patient had a PEG tube that the SNF managed. Clinical Record 9: The patient elected hospice care on 05/12/2023 with the diagnoses: Alzheimer's Disease and a stasis ulcer. The initial assessment on 05/12/2023 documented that the patient had a stasis ulcer. The SN assessments dated 06/24/2024 and 07/09/2024 documented that the patient had a stasis ulcer, which continued to be a problem. The hospice plan of care for the benefit period dated 07/05/2024 through 09/02/2024 did not identify which provider was responsible for performing the functions included in the plan of care. Following the joint record review on 07/102024, the Administrator, Regional Vice President of Operations, and Director of Clinical Services confirmed that the plans of care did not include evidence of consultation and collaboration with the SNF and did not specify who was responsible for the interventions.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident the most recent hospice plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 2 of 2 (100%) home visits observed of patients residing in a skilled nursing facility (SNF), the agency did not ensure that the SNF received each patient’s most recent hospice plan of care. Home Visit 2/Clinical Record 2: The patient elected hospice care on 05/22/2024 and resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 07/10/2024, the SNF did not have copies of the hospice plan of care. The hospice RN attempted to gather the required documents from the SNF medical records department, but the SNF did not have them. During an interview, the SNF nurse reported that the facility receives a medication list from the hospice, and there is not much other collaboration. Home Visit 3/Clinical Record 3: The patient elected hospice care on 09/20/2023 and resided in a SNF. During the home visit with the RN [Personnel Record 2] on 07/10/2024, a review of the patient's SNF medical record revealed that the most recent Interdisciplinary Group (IDG) plan of care update report was dated 04/25/2024. The SNF did not have the hospice plan of care for the benefit period dated 06/16/2024 through 08/14/2024. The hospice RN asked the SNF office staff to confirm that there was no current plan of care. The SNF office staff stated in part, "We always have a hard time getting the documents that we need from hospices." During an interview on 07/10/2024, the Regional Vice President of Operations, Administrator, and Director of Clinical Services confirmed the finding. The hospice leadership team reported that corporate could pull out a fax log to identify documents that were sent. Still, the agency had no process to verify receipt or a handling process to ensure the facility had them.