Every finding on record at Thi of Texas at Samaritan Hospice, LLC

It is required that work surfaces in the patient’s environment are cleaned as defined in the hospice’s infection prevention and control policies and procedures. This standard was not met as evidenced by interview, document review, and observation. Agency procedure #C_11G "Bag Technique and Standard Precautions" (Revision Date: 4/22/20) stated in part, "Appropriate hand hygiene is the gold standard and primary method of basic infection control practice. Hand hygiene is divided into two (2) aspects: a. Hand washing using soap and water b. Use of alcohol-based hand gel (sanitizer) when soap and water are not available or feasible for use …When to use hand gel (sanitizer)…After contact with inanimate objects in the patient’s environment." In 1 of 3 (33%) home visits observed, the agency did not ensure staff performed hand hygiene according to agency policy. Home Visit 2: The patient elected hospice care on 5/19/23 and resides in a skilled nursing facility (SNF). During the home visit on 11/7/23 with the Social Worker (MSW) [Personnel Record 4], the patient instructed the MSW to obtain a letter from the drawer. The MSW got the letter and placed it on the patient's bedside table. The patient's urinal was also on the patient's bedside table. After reading the patient's letter, the MSW placed the letter back into the drawer. The MSW did not perform hand hygiene after contact with the patient's letter and before holding their documentation device, the tablet. During an interview on 11/7/23, the Director of Clinical Services, present for the home visit, confirmed the finding.

It is required that the written Patient Bill of Rights includes the right to voice grievances to the hospice, CHAP, or a state entity without fear of discrimination or reprisal and voice grievances regarding treatment or care that is—or fails to be—provided. This standard was not met as evidenced by a review of documents, interviews, and observations. In 1 of 1 (100%) observation during a Home visit where the primary caregiver voiced dissatisfaction with hospice services from the agency revealed the agency did not follow its procedure for complaints and grievances. The Agency procedure C_06A titled Complaints and Grievances, stated in part under subtitle Procedure, "(4) the Director of Clinical Services or designee will be responsible for the following actions: (a) Complete the top portion of the written Complaint Report, (i) detail the complaint as related by colleagues and/or complainant, (ii) begin initial investigation of the complaint to include initial determination of nature of complaint, whether escalation to the internal compliance/legal team is needed, and take immediate corrective steps to mitigate concern if appropriate. (iii) Communicate with complainant regarding the progress of the investigation as needed. (5) The Area Executive of Clinical Services or designee will be responsible for the following actions: (b) Review progress of investigation within five (5) working days and determine appropriate corrective actions, including steps the supervisor may have already implemented. The investigation does not have to be completed in this time frame - it is appropriate for the ACO and DCS to conduct as thorough and comprehensive an investigation as the situation requires. The 5-day timeframe ensures follow-up, follow-through, and coordination of corrective actions can accomplished with an eye on ensuring service delivery is aligned with the agency's values. (e) Within 30 days of the receipt of the complaint, contact the complainant either via telephone or with a letter detailing the steps toward resolution and any further investigation required... (f) Complete supervisor section of the complaint form. (g) Complete the Complaint Log." A review of the agency's Complaint Log binder on 1/5/2023 revealed no documentation of past complaints previously voiced by the patient's granddaughter (Record 3). Home Visit 3: The patient with a hospice election of benefit dated 9/14/2022 was a hospice transfer to the current agency due to the patient moving in with her granddaughter. The transferring hospice previously providing services to the patient belonged to the same corporation as the current agency. During home visit #3 on 1/4/2022 with the Medical Social Worker, the granddaughter voiced frustration with inconsistency in personnel, not receiving medical supplies that were obtained from the previous hospice provider of the same corporation, precisely heavy absorbent incontinent supplies versus the light absorbent supplies currently receiving, and the request of daily nursing visits for symptom management concerns. Granddaughter stated she had voiced concerns in the past without resolution. Staff 6: After home visit #3, the Medical Social Worker (Staff 6) was interviewed on the complaints process. The Medical Social Worker confirmed the granddaughter had made complaints in the past. They stated they would notify their immediate supervisor of any complaints made by patients or families; however, they would not receive communication of its follow-up or follow-through. Interview with the Administrator on 1/5/2023 to discuss the granddaughter's complaints and concerns; the Administrator called the granddaughter to follow up with the grievances. The Administrator stated the requested supplies were ordered, and additional supplies were delivered the same day. The other concerns were addressed regarding staff inconsistency and symptom management, and a daily nursing visit was to be completed by an approved nurse of the granddaughter.

It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 1 of 2 (50%) clinical records reviewed for live discharges with revocation revealed the agency did not adhere to its policy and procedures of providing a patient's or representative's choice to revoke services or obtaining a signed written statement. The Agency policy C04, titled Discharge/Transfer/Revocation with effective date 8/1/2017 and revised 8/19/19, stated in part under subtitle Revocation, " (1) A patient may choose to stop hospice services at any time for any reason. (2) The patient or representative must file a statement with the (agency) program notifying them of the effective date of the revocation." Clinical Record 7: The patient with hospice election of benefit dated 8/31/2022 was discharged effectively on 11/3/2022 due to the reason of revocation because the patient was admitted to the local hospital for dehydration and constipation. The Hospice Discharge from Agency No Visit Made note dated 11/3/2022 documented in the narrative that the RN documented calling and speaking with someone at the local, regional hospital and being notified the patient was being admitted for dehydration and constipation. "The family wanted IV fluids to rehydrate the patient, and the MD ordered an enema. I let her (hospital staff) know the patient would be coming off service for (physician's name) orders." RN called the daughter and "explained the patient would have to be reevaluated once discharged from the hospital" and "explained that part of what hospice goal was to keep the patient from having to go to the hospital...we can manage things like constipation in the home." The RN also explained to the daughter "that when people are hospitalized, they have to come off hospital (hospice) services because, according to Medicare guidelines, they are seeking aggressive treatment, and she expressed understanding." No revocation form was located or documented in the record. The agency did not provide the daughter with the choice of revocation but instructed her of the agency discharge. The patient was readmitted to the agency effective 11/14/2022 after being discharged from the hospital. An interview with Administrator on 1/6/2023 confirmed a signed revocation form was not found in clinical record #7 during the joint record review, and the agency's procedure for revocations was not followed.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identify planned interventions based on problems identified in the initial and updated comprehensive assessments and includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. The documentation in the patient’s record is in accordance with the hospice’s policies and procedures. This standard was not met as evidenced by a review of clinical records, observations and interviews. In 7 of 11 (64%) clinical records reviewed revealed, the agency did not include DME and supplies in the patient's plan of care. Clinical Record 7: The patient with hospice election of benefit dated 8/31/2022 had a primary diagnosis of Alzheimer's. The Hospice Certification and Plan of Care dated 8/31/2022 for benefit period 8/31/2022 to 11/19/2022 document DME and supplies as "none" and functional limitation as incontinent of bowel and bladder and receiving oxygen; the patient was incontinent and used diapers. Hospice Certification and Plan of Care dated 11/14/2022 for benefit period 11/14/2022 to 1/12/2023 document DME and supplies as "none" and functional limitation as incontinent of bowel and bladder and receiving oxygen. Hospice RN Start of Care note dated 11/14/2022 documented bowel and bladder incontinence. Death Visit Note dated 12/6/2022 documented equipment/supplies to be removed: hospital bed, overbed table, and an oxygen concentrator. During the joint record review, the Administrator confirmed that the DME and supplies were not listed on the plan of care. The Administrator provided evidence that the patient received underpads, wipes, a wheeled walker, a hospital bed with an alternating pressure pad, an overbed table, a shower chair, and an oxygen concentrator from the agency. Clinical Record 6: The patient with hospice election of benefit dated 9/22/2022 had prostate cancer and COPD diagnoses. The patient had documented functional limitations of bowel and bladder incontinence. The Hospice Certification and Plan of Care dated 9/22/2022 for the benefit period 9/22/2022 to 11/20/2022 documented DME and supplies as "none." During the joint record review, the Administrator confirmed that the DME and supplies were not listed on the plan of care. The Administrator provided evidence that the patient received underpads, wipes, XL briefs, an oxygen concentrator, an alternate pressure pad, a hospital bed, over bed table, a wheelchair, a nebulizer setup, and a suction machine from the agency. Clinical Record 5: The patient with hospice election of benefit dated 10/7/2022 had breast cancer and Parkinson's diagnoses. The Hospice Certification and Plan of Care dated 10/7/022 for the benefit period 10/7/2022 to 1/4/2023 documented DME and supplies as "none." Hospice RN Start of Care note dated 10/7/2022 documented multiple stage 2 wounds and indwelling Foley catheter. In the narrative, RN documented DME ordered: hospital bed w/trapeze, bedside table, bedside commode, wheelchair, wedge pillow, and supplies to be ordered, including underpads, wipes, and wound care supplies. During the joint record review, the Administrator confirmed that the DME and supplies were not listed on the plan of care. The Administrator provided evidence that the patient received underpads, wipes, XL briefs, wound care supplies, a hospital bed w/trapeze, a bedside table, a bedside commode, and a wheelchair. Clinical Record 3: The patient with hospice election of benefit dated 9/22/2022 had a primary diagnosis of COPD. The Hospice Certification and Plan of Care dated 9/22/2022 for benefit period 9/22/2022 to 11/2/2022 document "none" for DME and Supplies. RN documented patient was incontinent of bowel and bladder and used a walker. During home visit #1, it was observed patient had a hospital bed, oxygen concentrator, and incontinent supplies, including wipes, underpads, and diapers. During the joint record review, the Administrator confirmed that the DME and supplies were not listed on the plan of care. The Administrator provided evidence that the patient received from the agency underpads, wipes, large briefs, oxygen, a shower chair, a bedside commode, a nebulizer setup, a suction machine, an overbed table, a wheelchair, a walker with wheels, and a hospital bed. Clinical Record 2: The patient with hospice election of benefit dated 9/14/2022 had a primary diagnosis of Heart Failure. The Hospice Certification and Plan of Care dated 9/14/2022 for the benefit period 9/14/2022 to 9/24/2022 documented DME and supplies as "none." Hospice Recertification Order dated 9/22/2022 for benefit period 9/25/2022 to 11/23/2022 had no documented DME or supplies. Hospice Recertification Order dated 11/22/2022 for benefit period 11/24/2022 to 1/22/2023 had no documented DME or supplies. Hospice RN Start of Care visit note dated 9/14/2022 documented incontinence and use of pullups. During home visit #2, it was observed that the patient had a hospital bed, a bedside commode, a wheelchair, and a shower chair and used incontinence supplies. Still, none of the items were listed on the plan of care provided by the agency. During the joint record review, the Administrator confirmed that the DME and supplies were not listed on the plan of care. The Administrator provided evidence that the patient received underpads, wipes, large pullups, a wheelchair, an oxygen concentrator, an overbed table, a rollator walker, a hospital bed, a bedside commode, an overbed table, a shower chair, a suction machine, a fall pad from the agency. Clinical Record 1: The patient with hospice election of benefit dated 9/12/2022 had a primary diagnosis of Senile Degeneration of the Brain. The Hospice Certification and Plan of Care dated 9/12/2022 for the benefit period 9/12/2022 to 9/28/2022 documented DME and supplies as none. RN documented on Plan of Care under Functional Limitations with bowel/bladder incontinence, endurance, ambulation, and speech, and Safety Measures included O2 Precautions. The Hospice RN Start of Care visit note dated 9/12/2022 documented the patient as "incontinent of bladder/bowel within the past year" and using pullups. "Patient walks with walker and transfers from bed to chair with assistance." "Skin integrity: darkened area at the coccyx." RN Hospice Recertification Assessment dated 9/26/2022 documented a gait belt and walker under the functional assistive device. Hospice Recertification Order dated 9/26/2022 for benefit period 9/29/2022-11/27/2022 DME and supplies missing and not documented. During the joint record review, the Administrator confirmed that the DME and supplies were not listed on the plan of care. The Administrator provided evidence that the patient received underpads, wipes, large pullups, a fall pad, a hospital bed, an overbed table, an oxygen concentrator, and a nebulizer machine from the agency. Clinical Record 10: The patient with hospice election of benefit dated 5/9/2022 had a primary diagnosis of Senile Degeneration of the Brain. The Hospice Certification and Plan of Care dated 5/9/2022 for the benefit period 5/9/2022 to 8/6/2022 documented "none" for DME and supplies. During the joint record review, the Administrator confirmed that the DME and supplies were not listed on the plan of care. In addition, the Administrator provided evidence that the patient received underpads, wipes, and small pullups from the agency.

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. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 5 of 5 (100%) clinical records for Bereavement Services reviewed revealed some interventions on the bereavement plan of care were missing their frequency of service delivery. Clinical Record 6: Patient with hospice election of benefit dated 9/16/2022 received bereavement services upon death dated 12/30/2022. The Bereavement Care Plan for a low-risk care plan type dated 9/23/2022 and last modified 12/30/2022 documented five (5) interventions without frequencies: a sympathy card, information regarding local grief support groups, an invitation to "remembrance gathering" memorial services, an invitation to holiday support meeting, and provide linkage to bereavement video modules to support identified grief needs. Clinical Record 7: Patient with hospice election of benefit dated 8/31/2022 received bereavement services upon death dated 12/6/2022. The Bereavement Care Plan for low-risk care plan type dated 11/18/2022 and last modified 12/28/2022 documented five (5) interventions without frequencies: a sympathy card, information regarding local grief support groups, an invitation to "remembrance gathering" memorial services, an invitation to holiday support meeting, and provide linkage to bereavement video modules to support identified grief needs. Clinical Record 8: Patient with hospice election of benefit dated 10/10/2022 received bereavement services upon death dated 11/7/2022. Bereavement Care Plan for low-risk care plan type dated 10/13/2022 and last modified 11/17/2022 documented five (5) interventions without frequencies: a sympathy card, information regarding local grief support groups, an invitation to "remembrance gathering" memorial services, an invitation to holiday support meeting, and provide linkage to bereavement video modules to support identified grief needs. Clinical Record 10: Patient with hospice election of benefit dated 5/9/2022 received bereavement services upon death dated 6/30/2022. Bereavement Care Plan for low-risk care plan type dated 6/9/2022 and last modified 6/9/2022 documented five (5) interventions without frequencies: a sympathy card, information regarding local grief support groups, an invitation to "remembrance gathering" memorial services, an invitation to holiday support meeting, and provide linkage to bereavement video modules to support identified grief needs. Clinical Record 11: Patient with hospice election of benefit dated 12/1/2022 received bereavement services upon death dated 1/2/2023. Bereavement Care Plan for low-risk care plan type dated 12/5/2022 and last modified 12/31/2022 documented five (5) interventions without frequencies: a sympathy card, information regarding local grief support groups, an invitation to "remembrance gathering" memorial services, an invitation to holiday support meeting, and provide linkage to bereavement video modules to support identified grief needs. The Agency policy C19, titled Bereavement Services effective 11/1/2017 and revised 1/14/2019 under subtitle Policy Provisions, stated in part, " (3) develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery." An interview with the Administrator and Bereavement Coordinator on 1/6/2023 confirmed the bereavement care plans' interventions identified were missing their frequencies during the joint review of the low-risk care plan type template.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below, and the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below, and the hospice maintains documentation that each hospice aide has met the requirements. Documentation of training includes a description of the training and competency evaluation program; the qualifications of the instructor; a statement that distinguishes skills taught in a laboratory using a real person (not a mannequin); indicators of which skills the aide was judged to be competent in; and how additional skills, if any, are taught and tested if the hospice’s admission policies and case-mix of hospice patients requires aides to perform more complex procedures. Hospice Aide Training and Competency Evaluation, A qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: a) Observation, reporting, and documentation of patient status and the care or service provided; b) Basic infection control procedures; c) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; d) Maintenance of a clean, safe, and healthy environment; e) Recognizing emergencies and the knowledge of emergency procedures and their application; f) The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; g) Adequate nutrition and fluid intake; h) Any remaining task(s) that the hospice chooses to have an aide perform. AND The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. AND A hospice aide is not considered competent in any task for which he or she is evaluated as “unsatisfactory.” A hospice aide may not perform that task without direct supervision by a registered nurse until after he/she has received training in the task for which he/she was evaluated as “unsatisfactory” and has successfully completed a subsequent evaluation. A hospice aide is not considered to have successfully completed a competency evaluation if the aide has an “unsatisfactory” rating in more than one (1) of the required areas. AND The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by a review of personnel records and interviews. In 1 of 1 (100%) personnel record of a hospice aide reviewed revealed the agency did not have documentation of the aide's initial or annual clinical competency assessment. Staff 9: The Hospice Aide with the date of hire of 4/26/2021 was missing evidence of an initial and annual competency completed by the agency. Interviews with the Administrator and the Human Resource representative on 1/5/2023 confirmed the Hospice Aide was missing the initial and annual clinical competency assessments.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by a review of personnel records and interviews. In 2 of 10 (20%) personnel records reviewed revealed, the agency did not have documentation of skills and competency assessments for employees providing direct patient care. Staff 10: The Registered Nurse with a date of hire of 11/7/2022 did not have a documented initial assessment of skills or competency during the joint personnel record review with the Human Resource representative on 1/5/2023. Staff 5: The Nurse Practitioner employee with a date of hire of 12/30/2021 did not have a documented initial or annual assessment of skills or competency during the joint personnel record review with the Human Resource representative on 1/5/2023. Interviews on 1/5/2023 with the Administrator and the Human Resource representative confirmed the competencies of Staff 5, Staff 9, and Staff 10 were missing.

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 available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 5 (100%) clinical records reviewed where patients who received assessments and treatments for wounds or surgically inserted devices did not have correct physician orders. Clinical Record 5: The patient with the hospice election of benefit dated 10/7/2022 was diagnosed with breast cancer and multiple wounds. The wound care verbal physician order created by LPN dated 10/12/2022 and signed by the physician on 10/26/2022 did not include the frequencies of treatments for the multiple stage II pressure ulcers located on the abdomen (#4, #5, #6, #7, #8) and buttocks/inner thigh (#9). The wound care verbal physician order created by LPN dated 10/28/2022 and signed by the physician on 11/8/2022 did not include the frequencies of treatments for the multiple stage II pressure ulcers located on the abdomen (#4, #7, #8) and buttocks/inner thigh (#9). The wound care verbal physician order created by LPN dated 10/31/2022 and signed by the physician on 11/8/2022 did not include the frequency of treatment for the skin tear to the suprapubic area. Clinical Record 7: The patient with the hospice election of benefit dated 8/31/2022 was diagnosed with Alzheimer's and wounds. The wound care verbal physician orders created by RN dated 10/31/2022 and 11/2/2022 and signed by the physician on 11/8/2022 did not include the frequency of the treatments for the stage 1 pressure ulcer to the coccyx and the skin breakdown to the left sacral area. Clinical Record 8: The patient with the hospice election of benefit dated 10/10/2022 was diagnosed with liver cancer and cirrhosis with ascites and had a chest PleurX drain for symptom management. The Hospice Certification and Plan of Care dated 10/10/2022 did not document treatment orders or a care plan for the PleurX catheter. The hospice RN's subsequent visit dated 10/21/2022 documented patient "has a pleural catheter which he managed before, but the patient claimed it has not been draining fluids for over a month." Twenty-two days after the start of care, the physician order dated 11/1/2022 was created by RN and signed by the physician on 11/8/2022, documenting "skilled nurse to perform pleurex drain per patient request." The physician order dated 11/6/2022 created by RN and signed by the physician on 11/8/2022 documented, "patient may drain thoracostomy catheter daily for end-of-life comfort, but not to exceed 1000mL per day." There were no physician orders for catheter care maintenance to prevent infection at the insertion site or verification assessment that the patient could perform drainage safely. Clinical Record 9: The patient with the hospice election of benefit dated 11/20/2022 had diagnoses of senile degeneration of the brain, Alzheimer's, and kidney disease. The wound care verbal physician orders dated 12/5/2022 created by LPN and signed by the physician on 12/5/2022 did not include the frequency of the treatment of the two different skin tears (wounds #3 and #4). The wound care verbal physician order dated 12/6/2022 created by LPN and signed by the physician on 12/20/2022 did not include the frequency of treatment for skin tear to the chin area. Clinical Record 11: The patient with the hospice election of benefit dated 12/1/2022 had diagnoses of senile degeneration of the brain and kidney disease. The wound care verbal physician orders dated 12/28/2022 created by LPN and signed by the physician on 12/30/2022 did not include the frequency of the treatment to the left buttock. The wound care verbal physician orders dated 12/29/2022 created by LPN and signed by the physician on 12/30/2022 did not include the frequency of the treatment of the stage I pressure ulcer to bilateral heels. An interview with the Administrator on 1/6/2023 confirmed the physician orders identified in Record 5, Record 7, Record 8, Record 9, and Record 11 were not concise or complete.

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 the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 2 of 5 (40%) clinical records reviewed that included live discharges where the patient was transferred to a facility revealed the hospice did not ensure a copy of the hospice discharge summary was sent to the receiving facility. Clinical Record 7: The patient with hospice election of benefit dated 8/31/2022 had a documented discharge of revocation effective 11/3/2022 and was admitted to a local hospital for dehydration and constipation. No documentation or evidence of the discharge summary was forwarded to the receiving hospital. Clinical Record 9: The patient with hospice election of benefit dated 11/20/2022 had a documented discharge of 12/9/2022 due to moving out of the service area because they transferred to a non-contracted facility. The patient was transferred to a local hospital by the direction of Adult Protected Services (APS) due to safety issues in the home. There was no documentation or evidence of the discharge summary forwarded to the receiving hospital by the agency. The Agency policy C04, titled Discharge/Transfer/Revocation under subtitles Policy Provisions and Discharge, stated in part, "(7) The agency will provide a discharge summary to the attending physician and/or receiving facility containing (a) treatments, symptoms and pain management information, (b) current plan of care, (c) latest physician's orders, (d) other documentation facilitating continuity of care and/or requested by the attending physician or receiving facility." The Administrator confirmed the discharge summaries for Record 7 and Record 9 were not sent to the receiving facilities during the joint record review.

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 a review of clinical records, documents, and interviews. In 1 of 5 (20%) clinical records reviewed for live discharges revealed the agency did not forward a copy of the discharge summary to the attending physician. Clinical Record 5: The patient with hospice election of benefit dated 10/7/2022 had a primary breast cancer diagnosis. The patient elected to revoke, effective 11/4/2022, from the agency to seek curative treatment for breast cancer with a local oncologist. RN documented a coordination note dated 11/7/2022 that the "patient is requesting to revoke hospice and continue to seek aggressive treatment with (physician's name inserted) and continue chemotherapy for her breast cancer. Revocation documentation completed by the family and signed." No documentation or evidence was provided of the discharge summary being forwarded to the attending physician or oncologist. The Agency policy C04, titled Discharge/Transfer/Revocation under subtitles Policy Provisions and Discharge, stated in part, "(7) The agency will provide a discharge summary to the attending physician and/or receiving facility containing (a) treatments, symptoms and pain management information, (b) current plan of care, (c) latest physician's orders, (d) other documentation facilitating continuity of care and/or requested by the attending physician or receiving facility." The Administrator confirmed on 1/5/2023 that there was no evidence or documentation of the discharge summary being forwarded to the attending physician or oncologist taking over the patient's medical care. The Administrator stated the marketer was provided the discharge summary to hand deliver to the oncologist. However, there was no evidence provided by the oncologist's office of the discharge summary forwarded by the agency after the agency stated they would give this evidence.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by observation and interviews. During an inspection of the office medical supply room on 1/6/2023 revealed expired supplies: one (1) box of 200 pads of alcohol prep pads expired 12/2022; one (1) box of 200 pads, alcohol prep pads expired 10/2022; three (3) packs of 50 wipes of 75% alcohol wipes expired 7/15/2022. The office medical supply room inspection on 1/6/2023 was witnessed by the Administrator and confirmed the expiration dates of the identified items. However, the Administrator and the VP of Quality and Standards stated the items had extended expiration dates due to the Emergency Use Authorization (EUA) of the organization's pandemic stockpile based on the Shelf Life Extension Program from the FDA. The agency did not provide the request for the manufacturers' approved extension of expiration dates. During an inspection of the office medical supply room on 1/6/2023, revealed expired supplies: one (1) box of 200 pads of McKesson alcohol prep pads expired 12/2022; one (1) box of 200 pads of Cardinal Health alcohol prep pads expired 10/2022; three (3) packs of 50 wipes of 75% alcohol wipes expired 7/15/2022.