Every finding on record at Tlc Home Health Care, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 9 (33%) applicable clinical records reviewed for patients receiving a comprehensive assessment, the agency did not ensure the comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The patient elected hospice services on 06/14/2023. The initial psychosocial assessment was completed by the social worker on 06/21/2023, seven (7) days after the election. There was no documentation of missed visits or reasoning why the assessment was late. Clinical Record 2: The patient elected hospice services on 12/12/2023. A missed visit was documented by hospice chaplain on 12/12/2023 related to the initial spiritual assessment and stated, "No answer when I attempted to contact them by phone." The record provided no additional documentation of follow-up to complete the initial spiritual assessment. Clinical Record 11: The patient elected hospice services on 02/10/2023. The initial psychosocial assessment was completed by the social worker on 02/17/2023, seven (7) days after the election. There was no documentation of missed visits or explanation why the assessment was late. During a daily wrap up conference with the Administrator, Director of Nursing (DON)/Alternate Administrator, and the Alternate Director of Nursing on 03/19/2024 the records were reviewed, and it was acknowledged that the assessments were late. There was no known explanation as to why the visits were late. The Administrator stated, "They [the social worker and chaplain] need to be calling the family daily until they are able to connect. And documenting it."

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 and interview. In 1 of 12 (8%) applicable clinical records reviewed for patients receiving a comprehensive assessment, the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Clinical Record 2: The patient elected hospice services on 12/12/2023. A missed visit was documented by hospice chaplain on 12/12/2023 related to the initial bereavement assessment and stated, "I left a voicemail for [removed name], attempting to arrange an appointment with them." The record provided no additional documentation of follow up to complete the initial bereavement assessment. During a daily wrap up conference with the Administrator, Director of Nursing (DON)/Alternate Administrator, and the Alternate Director of Nursing on 03/19/2024 it was stated by the DON that the chaplain was new to hospice and needed more education on hospice regulations regarding timeliness of assessments. The administrator added that he should have followed up daily until he reached the patient/family.

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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the organization did not ensure the patient's individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 4: The patient elected hospice services on 11/04/2023. The plan of care (POC) dated 11/04/2023 included a goal related to anxiety that stated, "Patient describes a reduction in the level of anxiety experienced." A pain goal also stated in part, "Patient will report satisfactory pain control". The initial nursing assessment dated 11/04/2023 indicated the patient was "unresponsive" and "non-verbal" therefore the POC goals indicating the patient will describe or report are unable to be measured. Clinical Record 7: The patient elected hospice services on 07/23/2023. The plan of care dated 07/23/2023 included a goal related to anxiety that stated, "Patient describes a reduction in the level of anxiety experienced." A pain goal also stated in part, "Patient will report satisfactory pain control". The initial nursing assessment dated 07/23/2023 indicated the patient was "sedated", "non-responsive", and "non-verbal" therefore the POC goals indicating the patient will describe or report are unable to be measured. During a daily wrap up conference with the Administrator, Director of Nursing/Alternate Administrator, and the Alternate Director of Nursing on 03/19/2024 the Administrator acknowledged these goals were non-measurable for nonverbal patients and indicated that the nurse likely meant for the family/caregivers to report satisfactory pain control and reduction in anxiety.

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 12 (8%) clinical records reviewed revealed the organization did not ensure medications necessary to meet the needs of the patient were included in the patient's individualized written plan of care. Clinical Record 9: The patient elected hospice services on 05/17/2023. A registered nurse visit note dated 06/08/2023 indicated in part, "Patient pain is controlled with Tylenol. Offered to get morphine daughter refused and Tylenol is effective for pain management." Also, "Daughter manages meds, pt takes without difficulty." There were no medications listed in the medication profile or the plan of care dated 05/17/2023. A physician order dated 06/08/2023 stated in part, "Continue - Hydrochlorothiazide Oral 12.5 MG 1 Tab(s) Take one tab by mouth Daily, continue - Metoprolol Succinate ER Oral 100 MG 1 Tab(s) Take one tablet by mouth Daily, [...] continue- Potassium Chloride Crys ER Oral 20 MEQ 2 Tab(s) Daily". During a daily wrap up conference with the Administrator, Director of Nursing (DON)/Alternate Administrator, and the Alternate Director of Nursing on 03/19/2024 the DON indicated that the nurse likely forgot to populate the medications from the order to the medication profile and plan of care.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 10 (10%) personnel files reviewed, the agency did not ensure that all disciplines participated in hospice sponsored in-service training, per organizational policy. Document 2: Organizational policy number H:3-015.1 (Revised December 2010) stated in part, "Mandatory in-services will be attended by all disciplines." Personnel Record 10: This contracted provider was hired on 09/04/2018. The personnel record provided no evidence of participation in hospice sponsored in-service training in 2021, 2022, 2023, or 2024 to date. During an interview and joint personnel file review with the Director of Nursing (DON)/Alternate Administrator and the Office Manager on 03/19/2024, it was stated by both that the agency was unaware that the medical director should be participating in in-service training. At the daily wrap up conference with the Administrator, Director of Nursing/Alternate Administrator, and the Alternate Director of Nursing on 03/19/2024, the administrator asked, "Can I ask you a question? How come I have never been told this before? Why has this never come up?" relating to the Medical Director needing to be involved in hospice sponsored in-service training.

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 an 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 2 of 9 (22%) applicable clinical records reviewed for patients needing hospice aide services, the organization did not ensure the registered nurse completed the written patient care instructions for the hospice aide. Clinical Record 6: The patient elected hospice services on 07/21/2023. The initial nursing assessment dated 07/21/2023 stated in part, "Is Hospice Aide needed? Yes" Plan of care order dated 07/21/2023 indicated a hospice aide frequency of "2/wk". The record provided no evidence of an aide plan of care established by registered nurse prior to death on 07/28/2023. There were also no hospice aide visits or missed visits documented in the patient's clinical record. Clinical Record 8: The patient elected hospice services on 02/25/2023 and the initial nursing assessment dated 02/25/2023 indicated in part, "Pt has 16 French foley cath." The aide plan of care created by the registered nurse on 02/25/2023 indicated in part, "Peri care every visit" and "Incontinent Care every visit". There was no written information provided to the aide that indicated the patient had a foley catheter or written instructions on how to handle the foley catheter during peri care or incontinent care. The box for "Catheter Care" was unchecked and left blank by the registered nurse. During the exit conference on 03/20/2024 with the Director of Nursing, the Administrator, the Office Manager, and the Alternate Director of Nursing, the administrator stated that the catheter care box should have been checked for clinical record 8 saying, "they know better than that." There was no explanation offered for the lack of written instructions for the hospice aide in clinical record 6. The Director of Nursing stated she was on a leave and the administrator thought this may have been a patient where the aide service was refused, and it was simply not documented but she could not recall the details.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review and interview. In 3 of 7 (43%) applicable clinical records reviewed for patients receiving hospice aide services, the organization did not ensure documentation that the hospice aide was supervised by a registered nurse making an on-site visit to the patient's home no less frequently than every fourteen (14) days. Clinical Record 5: The patient elected hospice services on 02/16/2023. Hospice aide visits were initiated once weekly per the aide plan of care dated 02/21/2023. The record provided no evidence of a registered nurse making an onsite hospice aide supervision visit from 02/22/2023, when aide services began, through 03/20/2023 (26 days). Clinical Record 8: The patient elected hospice services on 02/25/2023. Hospice aide services were occurring as ordered twice weekly per the aide plan of care dated 02/25/2023. The record provided no evidence of a registered nurse making an onsite hospice aide supervision visit from 03/20/2023 through 04/04/2023 (15 days). Clinical Record 13: The patient elected hospice services on 07/05/2022. Hospice aide visits were initiated twice weekly per the aide plan of care dated 01/01/2023. The record provided no evidence of a registered nurse making an onsite hospice aide supervision visit from 01/24/2023 through 02/09/2023 (16 days). During a daily wrap up conference with the Administrator, Director of Nursing (DON)/Alternate Administrator, and the Alternate Director of Nursing on 03/19/2024 the Administrator stated she does not understand how those visits were missed. All personnel present agreed that the visits were completed, and it was likely the clinicians simply forgot to document the aide supervision as stated by the DON.

It is required that all entries in the patient record 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 and interview. In 1 of 13 (8%) clinical records reviewed the physician orders for medication were not complete to include the route of administration. Organizational policy number H:5-00.21 (revised December 2010) indicated in part, "The components of the medication assessment used to determine patient and family/caregiver knowledge and skill related to medication administration will include, but not be limited to: Name dosage, route, duration, time, and usage of medication." Clinical Record 4: physician order dated 11/04/2023 stated in part, "Morphine 20mg/ml give 0.25ml every 4 hours as needed for pain nurse may titrate as needed." The medication order did not include the route the medication was to be administered. During a daily wrap up conference on 03/19/2024 with the Director of Nursing, the Administrator, the Office Manager, and the Alternate Director of Nursing, it was reviewed and acknowledged that the medication order was missing the route of administration. The Administrator stated that it was likely an oversight and that the nurses should be including complete instructions when taking orders from the physicians.