Every finding on record at Ultimate Plus Hospice LLC

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 and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure medications were reviewed and the drug profiled was updated. CLINICAL RECORD 7: This patient elected the hospice benefit 09/11/2024 with a terminal diagnosis of cerebral atherosclerosis. A review of the Registered Nurse (RN) clinical notes on 02/27/2025, stated that the patient was experiencing increased edema and Lasix was increased to from 20 mg by mouth per day to 40 mg by mouth per day. There was no documented evidence that the medication review occurred. The drug profile was reviewed for the dates of 02/27/2025-03/20/2025, and did not include the Lasix 40 mg by mouth one time per day. CLINICAL RECORD 10: This patient elected the hospice benefit 10/28/2023 with a terminal diagnosis of senile degeneration of the brain. The Registered Nurse (RN) documented on 10/28/2023, oxygen 3-4 liters per nasal cannula prn for oxygen saturation levels below 70% was ordered. The drug profile for the dates of 10/28/2023-03/19/2025 was reviewed and did not include Oxygen 3-4 liters per nasal cannula prn for oxygen saturation levels below 70%. In an interview conducted on 03/20/2025, the Director of Clinical Services stated that the medications that were listed in the clinical documentation were not added to the drug profile.

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. 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 needs identified in the comprehensive assessments were added to the plan of care. CLINICAL RECORD 1: This patient elected the hospice benefit 02/24/2024 with a hospice diagnosis of congestive obstructive pulmonary disease. In review of the clinical record, the Registered Nurse (RN) wrote a communication note on 02/12/2025 which stated that the patient's caregiver was updated on the patient's condition of a temperature of 99.7 and documented the caregiver requested an antibiotic. A physician's order dated 02/12/2025 prescribed Macrodantin 100 mg twice a day for 10 days for a urinary tract infection. The plan of care was reviewed from 02/12/2025 to 03/18/2025. There was no update to the plan of care to address the infection. CLINICAL RECORD 2: This patient elected the hospice benefit 10/19/2022 with a terminal diagnosis of hypertensive heart and chronic kidney disease with a co-morbidity of Type 2 Diabetes Mellitus. In review of the clinical record, The Registered Nurse (RN) comprehensive assessment dated 10/19/2022, documented that the family was to check the patient's blood sugar levels and report the highs and lows. Novolog Flexpen subcutaneous pen-injector 100 units/ml 2 units as needed was started 10/19/2022 and Levemir subcutaneous solution 100 unit/ml 5 ml every morning was started on 11/04/2022. A review of the plans of care for dates of 10/19/2022- 03/20/2025 revealed there were no interventions for diabetes. CLINICAL RECORD 10: This patient elected the hospice benefit 10/28/2023 with a terminal diagnosis of senile degeneration of the brain. In review of the Nurse Practitioner (NP) notes for 07/26/2024, it was documented that the patient was having nausea and vomiting after eating. The NP ordered Ondansetron 8 mg three times a day and Prochlorperazine Maleate 10 mg every six as needed for nausea. A review of the plan of care dated 07/26/2024- 03/20/2025 revealed there was no interventions for nausea and vomiting. CLINICAL RECORD 12: This patient elected the hospice benefit 01/03/2025 with a terminal diagnosis of malignant neoplasm of bone and right kidney. The review of the Registered Nurse (RN) clinical documentation on 03/05/2025 stated the patient was started on Cipro 500 mg twice a day for 10 days for a urinary tract infection. A review of the plan of care dated 03/05/2025-03/20/2025 revealed there was no care plan for infection. The RN documentation on 03/18/2025 stated the patient had a change of condition and was declining. The plan of care was reviewed for dates of 03/18/2025-03/20/2025. There was no update to the plan of care for patient decline. An interview was conducted on 03/20/2025, and the Director of Clinical Services stated that the plan of care was not updated to include the changes in the patient's condition.

It is required that each patient’s individualized written plan of care 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 3 of 19 (16%) clinical records reviewed, the agency did not ensure that each patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 8: This patient elected the hospice benefit 09/24/2024 with a terminal illness of chronic ischemic heart disease. The goal for the care plan for cardiac was the patient/caregiver would receive optimal teaching, and symptoms would be managed at an acceptable level. There was no documentation of the patient goal for the acceptable level or measurable. CLINICAL RECORD 10: This patient elected the hospice benefit 10/28/2023 with a terminal diagnosis of senile degeneration of the brain. The patient goal for the care plan for pain was manage patient symptoms at an acceptable level. This goal was not measurable. CLINICAL RECORD 13: This patient elected the hospice benefit 07/09/2024 with a terminal diagnosis of cerebral atherosclerosis. A care plan was added for pain on 07/09/2024 for pain. The patient goal was symptoms will be managed at an acceptable level. This goal was not individualized or measurable. An interview was conducted on 03/20/2025, and the Director of Nursing stated the goals for the problems in the plan of care did not seem specific to the patient.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 4 (25%) home visits conducted revealed that the agency did not follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. DOCUMENT 1: Agency policy Hand Hygiene, Policy No. IC.15, last reviewed 09/01/2024, stated, in part: "All hospice staff providing patient care will perform hand hygiene in accordance with the Centers for Disease Control and Prevention (CDC) recommendations." " Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations listed below: 8. After removing gloves." HOME VISIT 2: During Home Visit 2 (Clinical Record 2) on 03/19/2025 to observe the hospice aide (Personnel Record 2), the hospice aide was observed giving the patient a bed bath. The hospice aide was observed removing gloves, reaching into the supply bag and retrieving gloves, without sanitizing hands as per hand hygiene policy. During an interview on 03/19/2025, the Director of Nursing stated that the agency policy for hand hygiene was to sanitize hands after removing gloves.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that nursing services were provided as per the plan of care. CLINICAL RECORD 14: This patient elected the hospice benefit 08/12/2024 with a terminal diagnosis of senile degeneration of the brain. The plan of care dated 01/09/2025 ordered skilled nursing visits two times a week. In review of the clinical record, the following skilled nursing visits were performed as follows: the week of 01/12/2025-01/18/2025, one visit was completed on 01/12/2025, the week of 01/19/2025-01/25/2025, one skilled nursing visit was completed on 01/20/2025, the week of 01/26/-02/01/2025- one skilled nursing visit was completed on 01/27/2025, the week of 02/02/2025-02/08/2025, one visit was completed on 02/03/2025, the week of 02/09/2025-02/15/2025, one visit was completed on 02/10/2025. This did not meet the frequency order of skilled nursing visits two times per week. There was no documentation of notification of missed visits present in the clinical record. In an interview conducted on 03/20/2025, the Director of Nursing stated that the plan of care was not followed for skilled nursing visits.

It is required that medical social services are provided by a qualified social worker based on a psychosocial assessment and per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed in which patients requested medical social worker visits, the agency did not ensure that medical social services were provided based on the plan of care. CLINICAL RECORD 3: This patient elected the hospice benefit 12/19/2023 with a hospice diagnosis of diffuse large B-cell lymphoma. The clinical record reviewed revealed that the plan of care dated 12/31/2024 ordered Medical Social Worker (MSW) visits one time a month. In review of the clinical record documentation for January 2025 and February 2025, there was no documentation that a MSW conducted a visit and there was no documentation of missed visits. In an interview conducted with the Director of Clinical Services on 03/20/2025, it was stated that the agency was out of compliance with the frequency orders written in the plan of care for MSW visits.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the documentation of the volunteer hours that were provided for 2024 did not equal five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The total patient care hours of all paid hospice employees and contract staff equaled 1.02% for the year 2024. In an interview conducted with the Director of Clinical Services on 03/20/2025, it was stated that the volunteer hours did not equal, at a minimum, 5 percent of the total patient care hours of all paid hospice employees and contract staff. (1.02%) A review of the documentation of the volunteer hours that were provided for 2024 did not equal five percent of the total patient care hours of all paid hospice employees and contract staff. In an interview conducted with the Director of Clinical Services on 03/20/2025, it was stated that the volunteer hours did not equal, at a minimum, 5 percent of the total patient care hours of all paid hospice employees and contract staff. (1.02%)

It is required that a governing body assumes full legal authority and responsibility for the organization’s: Overall management and operation; Provision of care and services. The standard was not met during the site visit, as evidenced by reviews of clinical records and documents, which revealed that the governing body did not fully assume legal responsibility and oversight for managing hospice operations, which is necessary to ensure Medicare approval for all locations. There was no documented evidence that the governing body addressed the operations of the ADS without Medicare approval. The Approved Medicare Enrollment Record report dated 02/28/2025 included the Parent location and one of the two Alternate Delivery Sites (ADS). However, the Medicare approval for the second operational ADS was missing.

It is required that a hospice operating hospice multiple location, also known as alternative delivery sites (ADS), ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. This standard was not met as evidenced by document review, interview, and observation. A review of the documents Approved Medicare Enrollment Record, report dated 02/28/2025 for the alternate delivery sites (ADS) revealed the agency did not ensure one of the two hospice multiple location was approved by Medicare as an alternate delivery site. A review of the organizational chart only identified the parent location. There was no documented evidence on the organizational chart that included the ADS. The Approved Medicare Enrollment Record included the Parent and one of the two ADS. In addition, a review of the active census on 03/18/2025 revealed the Parent location had an active census of 29 patients, one ADS approved by Medicare had an active census of 36 patients, and a second hospice multiple location not approved by Medicare had an active census of 26 patients. Clinical Record reviews included Parent location 4 records; approved hospice multiple location 6 records; and the not approved hospice multiple location 7 records. Home visits were conducted that included Parent location 2 home visits, approved hospice multiple location 1 home visit and the not approved hospice multiple location 1 home visit. During the entrance conference held on March 18, 2025, attendees included the President, Vice President of Operations, Administrator, Director of Clinical Services, Director of Nursing, Director of Quality, and Director of Compliance. The discussion focused on the three locations, covering activities such as site visits, home visits, clinical record reviews, and personnel record reviews.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. 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 record included physician orders. CLINICAL RECORD 7: This patient elected the hospice benefit on 09/11/2024 with a terminal diagnosis of cerebral atherosclerosis. A review of the Registered Nurse clinical notes on 02/27/2025, identified that patient was experiencing increased edema and Lasix was increased from 20 mg by mouth per day to 40 mg by mouth per day. The clinical record was reviewed for the dated of 02/27/2025-03/20/2025, and there was no physician's order for the increase in Lasix from 20 mg by mouth per day to 40 mg by mouth per day. In an interview conducted on 03/20/2025 with the Director of Clinical Services, it was stated that there was no physician orders present in the clinical record for the increase in Lasix.

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/IID 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, interview, and observation. In 2 of 7 (29%) clinical records reviewed where patients resided in the skilled nursing facility, the agency did not ensure that the care and services that were needed were identified and did not specify which provider was responsible for performing the functions that were agreed upon were included in the plan of care. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit 02/24/2024 with a terminal diagnosis of congestive obstructive pulmonary disease. In review of the plan of care from the dates of 02/24/2024-03/18/2025, there was no documentation of who responsible for performing the care and services that were needed. During the home visit conducted in the skilled nursing facility (SNF) on 03/18/2025 to observe the medical social worker (MSW) (Personnel Record 1), the hospice binder was reviewed and there was no documentation present for the delineation of duties form which the agency places in the SNF binder to document care and services that are needed and to specify which provider is responsible for performing the functions. CLINICAL RECORD 13: This patient elected the hospice benefit 07/09/2024 with a terminal diagnosis of cerebral atherosclerosis. The patient resided in a SNF. In review of the plan of care for dates of 07/09/2024-03/20/2025, there was no documentation of which provider was responsible for performing the care and services that were needed. An interview was conducted on 03/18/2025, and the MSW stated that the hospice binder in the SNF did not include the patient's/residents most recent hospice plan of care. In an interview conducted on 03/20/2025, the Director of Clinical Services stated that the agency did not have documentation in the clinical record for the delineation of duties for these patients who resided in the SNF.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: names and contact information for hospice staff involved in the patient’s care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 2 (50%) home observations conducted in the skilled nursing facility, the agency did not ensure that the designated IDG member provided the skilled nursing facility with the following information for each patient/resident: names and contact information for hospice staff involved in the patient’s care. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit 02/24/2024 with a terminal diagnosis of congestive obstructive pulmonary disease and resided in a skilled nursing facility. During the home visit to observe the medical social worker (MSW) (Personnel Record #1) on 03/18/2025, the names and contact information for hospice staff involved in the patient’s care was not complete. An interview was conducted on 03/18/2025, and the MSW stated that the hospice binder in the SNF did not include a complete list of names and contact information for hospice staff involved in the patient’s care.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. Development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment, and the documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed revealed that the agency did not ensure a completed individualized emergency plan was being discussed with and provided to the patient/family and maintained by the agency. Clinical Record 1: The patient elected the hospice benefit on 1/20/2023. There was no documented evidence in the clinical record of a completed individualized emergency plan. The initial nursing assessment dated 9/27/2023 had evidence of the family reporting -- In case of natural disaster, where will patient go? Government Shelter. Clinical Record 2: The patient elected the hospice benefit on 1/20/2023. There was no documented evidence in the clinical record of a completed individualized emergency plan. The initial nursing assessment dated 9/27/2023 had evidence of the family reporting -- In case of natural disaster, where will patient go? Follow facility protocol. Clinical Record 3: The patient elected the hospice benefit on 4/7/2023. There was no documented evidence in the clinical record of a completed individualized emergency plan. Clinical Record 4: The patient elected the hospice benefit on 9/27/2023. There was no documented evidence in the clinical record of a completed individualized emergency plan. The initial nursing assessment dated 9/27/2023 had evidence of the family reporting -- In case of natural disaster, where will patient go? Nearest Church. The Director of Nursing stated in an interview on 12/27/2023 that the agency did not ensure a completed individualized emergency plan was being discussed with and provided to the patient/family and maintained by the agency.

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 2 of 4 (50%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included completion of an initial bereavement assessment . Clinical Record 1: The patient elected the hospice benefit on 1/20/2023. There was no documented evidence in the clinical record of an initial bereavement assessment. The record had evidence of multiple phone calls from the chaplain to the patient’s family on 1/20/2023; 2/10/2023; 2/24/2023; and 3/17/2023. There was a completed initial chaplain visit on 4/19/2023, but no documented evidence of an initial bereavement assessment being completed that day. Clinical Record 3: The patient elected the hospice benefit on 4/7/2023 There was no documented evidence in the clinical record of an initial bereavement assessment. A communication note by the chaplain dated 4/10/202023 stated that the chaplain attempted a phone call to the son to complete the initial bereavement assessment. There was no documented evidence of any further follow-up. The Director of Nursing in an interview on 12/27/2023 stated that the agency did not ensure that the comprehensive assessment included completion of an 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. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed revealed that 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 2: The patient elected the hospice benefit on 11/7/2023. A physician order dated 12/8/2023 stated "Order given to drain patient with peritoneal drain as needed to keep comfortable. Do not exceed more than 2000 milliliters per procedure. The POC dated 12/14/2023 did not include evidence of goal(s) and intervention(s) for draining the ascites from peritoneal drain. Clinical Record 3: The patient elected the hospice benefit on 4/7/2023. The certificate of terminal illness dated 4/7/2023 stated the patient had bladder and bowel incontinence. The POC dated 4/7/2023 did not include evidence of goal(s) and intervention(s) for bladder and bowel incontinence. The Director of nursing stated in an interview on 12/27/2023 that the POCs lacked goal(s) and intervention(s) for patient problems identified in the initial and updated comprehensive assessments.

It is required Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. 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 clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patients discharged due to death revealed that the agency did not ensure a bereavement POC that included the types of bereavement services to be offered and the frequency of service delivery was completed post-death. Clinical Record 3: The patient elected the hospice benefit on 4/7/2023 and died on 12/9/2023. There was no documented evidence in the clinical record that a post-death bereavement assessment and POC were competed. Clinical Record 4: The patient elected the hospice benefit on 9/27/2023 and died on 10/19/2023. There was documentation of a post-death bereavement assessment on 10/20/2023 and a sympathy card sent on 11/3/2023. There was no document evidence of a post-death bereavement POC. The Director of Nursing stated in an interview on 12/27/2023 that the agency did not ensure a bereavement POC that included the types of bereavement services to be offered and the frequency of service delivery was completed post-death.

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 and interview. In 1 of 4 (25%) clinical records reviewed for patients that elected aide services revealed that the agency did not ensure that the aide provided services included on the plan of care (POC). Clinical Record 3: The aide plan of care dated 10/4/2023 ordered the task: shampoo hair 1 time per week. There was no documented evidence the shampoo hair task was done 1 time for the week of 10/8/2023. Aide visit notes dated 10/9/2023, 10/11/2023, and 10/13/2023, the aide documented "Not required" for Shampoo Hair for each visit. The Director of Nursing stated in an interview on 12/27/2023 that the aide did not provide services included on the aide POC.

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 1 of 2 (50%) clinical records reviewed for patient's that were residing at a skilled nursing facility (SNF) and elected the hospice benefit revealed that the agency did not ensure the plan of care (POC) specified which provider was responsible for performing the functions that were agreed upon and included in the POC. Clinical Record 3: The patient elected the hospice benefit on 4/7/2023 and resided in a SNF. The clinical record lacked evidence of which provider was responsible for performing the functions that were agreed upon and included in the POC. There was no documented evidence of the delineation of service form. The Director of Nursing in an interview on 12/27/2023 stated that the agency did not ensure the POC specified which provider was responsible for performing the functions that were agreed upon and included in the POC. They have a delineation of service form that they weren’t using.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. 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; the frequency of service delivery. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 1 of 2 (50%) clinical records reviewed of patients with a discharge due to death revealed the hospice did not ensure to provide evidence that a bereavement care plan was developed for the bereaved. The agency policy #PC.130 “Bereavement,” stated in part, “After the death of the patient, the Bereavement Coordinator will complete a follow -up assessment and develop a POC for bereavement services based on the re-assessment.” Record 5: The patient elected hospice care on 6/8/2022. A review of the record revealed no documentation of a bereavement care plan developed for the bereaved of the patient that expired on 7/2/2022. The Bereavement Coordinator was interviewed on 1/9/2023 and agreed, there was no documented evidence a bereavement plan of care was developed. The Bereavement Coordinator stated, “it appears they accepted bereavement so they should have a plan of care.” The Director of Nursing was interviewed on 1/9/2023 and agreed, there was no documented evidence a bereavement plan of care was developed. Agency policy, “Bereavement, PC.130,” stated in part, “After the death of the patient, the Bereavement Coordinator will complete a follow up assessment and develop a POC for bereavement services based on the re-assessment.” Record 5: The patient’s date of election was 6/8/2022. The bereavement record was reviewed and revealed the patient died on 7/2/2022. There was no documented evidence that a bereavement plan of care was developed. The Bereavement Coordinator was interviewed on 1/9/2023 and agreed, there was no documented evidence a bereavement plan of care was developed. The Bereavement Coordinator stated, “it appears they accepted bereavement so they should have a plan of care.” The Director of Nursing was interviewed on 1/9/2023 and agreed, there was no documented evidence a bereavement plan of care was developed.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by a review of personnel records, interviews, and document reviews. 3 of 5 (60%) personnel records of hospice aides reviewed revealed the hospice did not ensure that a competency assessment was completed upon hire as per the agency's policy. The agency policy, “Hospice Aide/Homemaker Competency Evaluation,” stated in part, “The Hospice will ensure that each Hospice Aide successfully completes a hospice aide skills and competency evaluation prior to the aide performing care independently. The competency evaluation and skills checklist will be administered by a Registered Nurse and will be scheduled during the orientation period. The Registered Nurse will document observation of skills as required and will sign and date the completed checklist.....” Staff 1: The Hospice Aide was hired on 9/6/2022. A review of the personnel record revealed evidence of an oral competency administered by the Registered Nurse and completed by the aide. There was no documented evidence that a skills competency evaluation was completed according to hospice policy. Staff 3: The Hospice Aide was hired on 7/18/2022. A review of the personnel record revealed evidence of an oral competency administered by the Registered Nurse and completed by the aide. There was no documented evidence that a skills competency evaluation was completed according to hospice policy. Staff 6: The Hospice Aide was hired on 11/10/2022. A review of the personnel record revealed evidence of an oral competency administered by the Registered Nurse and completed by the aide. There was no documented evidence that a skills competency evaluation was completed according to hospice policy. The Director of Nursing was interviewed on 1/9/2023 and agreed, there was no documented evidence that the skills competency evaluations were completed upon hire. The Director of Nursing confirmed the hospice aides identified have been making visits and stated, these should have been completed before the staff made independent visits.” Agency policy, “Hospice Aide/Homemaker Competency Evaluation,” stated in part, “The Hospice will ensure that each Hospice Aide successfully completes a hospice aide skills and competency evaluation prior to the aide performing care independently. The competency evaluation and skills checklist will be administered by a Registered Nurse and will be scheduled during the orientation period. The Registered Nurse will document observation of skills as required and will sign and date the completed checklist. The following subject areas must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient: Communication; reading and recording temperature, pulse and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks including: bed bath, sponge, tub and shower bath, hair shampooing in sink, tub and bed, nail and skin care, oral hygiene, toileting and elimination, normal range of motioning, safe transfer techniques and ambulation.” Record 1 (Hospice Aide): hire date 9/6/2022. There was no documented evidence that a skills competency evaluation was completed according to hospice policy. Record 3 (Hospice Aide): hire date 7/18/2022. There was no documented evidence that a skills competency evaluation was completed according to hospice policy. Record 6 (Hospice Aide): hire date 11/10/2022. There was no documented evidence that a skills competency evaluation was completed according to hospice policy. The Director of Nursing was interviewed on 1/9/2023 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Director of Nursing confirmed the hospice aides identified have been making visits and stated, these should have been completed before the staff made independent visits.”

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) clinical records reviewed revealed that hospice aide visits were not completed as ordered on the plan of care (POC). Record 1: The patient elected hospice care on 8/18/2022. The POC dated 9/7/2022 ordered hospice aide services "5 times a week." During the week of 10/9/2022 through 10/16/2022, hospice aide visits were completed on 10/10/2022, 10/11/2022, 10/12/2022, and 10/13/2022. The actual frequency was four times a week for one week. There was no evidence of a documented missed visit or communication with the physician changing the frequency of aide visits. During the week of 11/20/2022 through 11/26/2022, hospice aide visits were completed on 11/21 and 11/25. The actual frequency was two times a week for one week. There was no evidence of documented missed visits or communication with the physician changing the frequency of aide visits. Record 5: The patient elected hospice care on 6/8/2022. The POC dated 6/12/2022 ordered hospice aide services "5 times a week." During the week of 6/12/2022 through 6/18/2022, hospice aide visits were completed on 6/13/2022, 6/14/2022, 6/15/2022, and 6/17/2022. A missed visit documented on 6/16/2022 read in part, “aide was not able to get to the facility due to transportation problem.” During the week of 6/19/2022 through 6/25/2022, hospice aide visits were completed on 6/21/2022, 6/22/2022, 6/23/2022, and 6/24/2022. A missed visit documented on 6/20/2022 read in part, “aide unable to get to facility today.” During the week of 6/26/2022 through 7/2/2022, hospice aide visits were documented on 6/27/2022, 6/28/2022, 6/30/2022, and 7/1/2022. A missed visit documented on 6/29/2022 read in part, “aide was unable to get to facility.” The Director of Nursing was interviewed on 1/9/2023 and agreed, the hospice aide visits were not completed as ordered. The Director of Nursing stated, the missed visits should have been scheduled with another aide since the patient or family did not cancel. Record 1: The patient’s date of election was 8/18/2022. The patient’s date of election was 8/18/2022. The plan of care on 9/7/2022 ordered a hospice aide 5 x week. During the week of 9/18/2022-9/24/2022, hospice aide visits were documented on 9/19, 9/23 and 9/24. A missed visit was documented on 9/20/2022 “family emergency,” and 9/21/2022 did not have a documented reason for the missed visit. During the week of 10/9/2022-10/16/2022, hospice aide visits were documented on 10/10, 10/11, 10/12 and 10/13. There was no documented evidence of a fifth hospice aide visit or documented reason for the missed visit. During the week of 11/20/2022-11/26/2022, hospice aide visits were documented on 11/21 and 11/25. There was no documented evidence of a third, fourth or fifth hospice aide visit or documented reason for the missed visit. Record 5: The patient’s date of election was 6/8/2022. The plan of care on 6/12/2022 ordered a hospice aide 5 x week. During the week of 6/12/2022-6/18/2022, hospice aide visits were documented on 6/13, 6/14, 6/15 and 6/17. A missed visit was documented on 6/16/2022 “aide was not able to get to the facility due to transportation problem.” During the week of 6/19/2022-6/25/2022, hospice aide visits were documented on 6/21, 6/22, 6/23 and 6/24. A missed visit was documented on 6/20/2022 “aide unable to get to facility today.” During the week of 6/26/2022-7/2/2022, hospice aide visits were documented on 6/27, 6/28, 6/30 and 7/1. A missed visit was documented on 6/29/2022 “aide was unable to get to facility.” The Director of Nursing was interviewed on 1/9/2023 and agreed, the hospice aide visits were not completed as ordered. The Director of Nursing stated, the missed visits should have been scheduled with another aide since the patient or family did not cancel.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) clinical records reviewed revealed the hospice did not ensure that all entries in the patient's clinical record were appropriately authenticated by the person performing the care/service. Record 1: The patient elected hospice care on 8/18/2022. A review of the clinical record revealed the nursing assessment dated 12/29/2022 was not authenticated with the title of the person performing the care/service. Record 3: The patient elected hospice care on 10/19/2022. A review of the clinical record revealed the aide visit note dated 10/24/2022, the nursing visit note dated 10/21/2022, and the social worker visit note dated 11/9/2022 were not authenticated with the title of the person performing the care/service. The Director of Nursing was interviewed on 1/9/2023 and agreed, the entries were not properly authenticated with the staff’s title in the signature line. The Director of Nursing stated, “we missed adding these but are working on them now.” Record 1: The patient’s date of election was 8/18/2022. The nursing assessment on 12/29/2022 was reviewed. There was no documented evidence the entry was authenticated with the title of the person performing the care/service. Record 3: The patient’s date of election was 10/19/2022. The aide documentation on 10/24/2022 was reviewed. The nursing documentation on 10/21/2022 was reviewed. The social worker documentation on 11/9/2022 was reviewed. There was no documented evidence the entries were authenticated with the title of the person performing the care/service. The Director of Nursing was interviewed on 1/9/2023 and agreed, the entries were not properly authenticated with the staff’s title in the signature line. The Director of Nursing stated, “we missed adding these but are working on them now.”

It is required that the hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 3 (67%) clinical records reviewed of patients residing in a SNF revealed the hospice did not ensure that the plan of care specified which provider was responsible for performing the functions that were agreed upon based upon the needs of the patient. . Record 1: The patient elected hospice care on 8/18/2022. The plan of care did not specify which provider was responsible for performing the functions that were agreed upon, based on the needs of the patient. Record 5: The patient elected hospice care on 6/8/2022. The plan of care did not specify which provider was responsible for performing the functions that were agreed upon, based on the needs of the patient. The Director of Nursing was interviewed on 1/9/2023 and stated, the admission nurses and RN case managers are required to complete a delineation of duties form for all SNF patients and upload the completed form to the EMR. The Director of Nursing stated, “it looks like these were not completed so we have no evidence the delineation was documented, more education is needed.” Record 1: The patient’s date of election was 8/18/2022. There was no documented evidence the plan of care specified which provider was responsible for performing the functions that were agreed upon, based on the needs of the patient. Record 5: The patient’s date of election was 6/8/2022. There was no documented evidence the plan of care specified which provider was responsible for performing the functions that were agreed upon, based on the needs of the patient. The Director of Nursing was interviewed on 1/9/2023 and stated, the admission nurses and RN case managers are required to complete a delineation of duties form for all SNF patients and upload the completed form to the EMR. The Director of Nursing stated, “it looks like these were not completed so we have no evidence the delineation was documented, more education is needed.”

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of COVID-19 vaccine, or the first dose of the primary series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families. This standard was not met as evidenced by interviews and personnel records review. 3 of 6 (50%) personnel records reviewed revealed the hospice did not ensure that individuals eligible to be fully vaccinated for COVID-19. were fully vaccinated for COVID-19. Staff 1: The Hospice Aide was hired on 9/6/2022. A review of the personnel file revealed there was no documented evidence of COVID vaccination or an approved or pending exemption. Staff 4: The Registered Nurse was hired on 10/17/2022. A review of the personnel file revealed there was no documented evidence of COVID vaccination or an approved or pending exemption. Staff 5: The Social Worker was hired on 10/10/2022. A review of the personnel file revealed there was no documented evidence of COVID vaccination or an approved or pending exemption. The Human Resources Director was interviewed on 1/9/2023 and stated, “the personnel files are a mess, I don’t have proof they are vaccinated or have an approved exemption.” The Alternate Administrator was interviewed on 1/9/2023 and confirmed this finding. Record 1 (Hospice Aide): hire date 9/6/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record 4 (Registered Nurse): hire date 10/17/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. Record 5 (Social Worker): hire date 10/10/2022. There was no documented evidence of COVID-19 vaccination or COVID-19 vaccination exemption prior to providing care. The Human Resources Director was interviewed on 1/9/2023 and stated, “the personnel files are a mess, I don’t have proof they are vaccinated or have an approved exemption.” The Alternate Administrator was interviewed on 1/9/2023 and confirmed this finding.

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 review of records and interview. In 3 of 13 (8%) records reviewed it was revealed the agency failed to complete the initial assessment no later than 5 calendar days after election of hospice care. In review of Record #45965 it was identified that the patient was admitted 6/8/2021 and no documentation was present that the MSW completed a psychosocial assessment visit no later than 5 calendar days after election of hospice care. In review of Record #30717 it was identified that the patient was admitted 11/12/2021 and no documentation was present that the MSW completed a psychosocial assessment no later than 5 calendar days after election of hospice care. In review of Record #56198 it was identified that the patient was admitted 1/20/2022 and no documentation was present that the MSW completed a psychosocial assessment no later than 5 calendar days after election of hospice care. In an interview with the Director of Nursing on 4/1/2022 it was confirmed that the initial comprehensive assessment was not completed no later than 5 calendar days after the election of hospice care and there was no additional information provided.

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 record review and interview. 1 of 13 (8%) records failed to provide documentation of an initial bereavement assessment. In review of Record #45965 it was identified that the patient was admitted 6/8/2021 and no documentation of a bereavement risk assessment was provided from the review dates of 6/8/2021-3/31/2022. During an interview with the Administrator, President, and the Director of Nursing on 3/31/2022 the finding was confirmed and no additional information was provided.

It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by review of records and interview. 1 of 13 (8%) clinical records failed to provide education to the patient and caregivers regarding a new medication that was ordered. In review of Record #72523 it was identified in the RN assessment completed on 12/18/2021 that Tramadol was ordered for the patient's complaint of pain. There was no evidence in the documentation or in the POC that the patient or caregiver was provided education on the indication for the medication, the appropriate dosage and time or the side effects of the medication. During an interview with the Administrator, President, and the Director of Nursing on 3/31/2022 the finding was confirmed and no additional information was provided.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: 1. As frequently as the patient's condition requires; but 2. No less frequently than every 15 calendar days. A revised plan of care includes: 1. Information from the patient’s updated comprehensive assessment; 2. Record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by record review and interview. 2 of 13 (23%) records reviewed failed to provide documentation that the POC was updated when the patient's condition changed. In review of Record #56198 it was documented that the LVN made a routine visit on 1/19/202 to provide wound care. During this visit, the LVN noted the patient was declining and having dyspnea. She called to notify the Director of Nursing. The RN made a visit to the patient and received orders to start comfort medications. The POC was not updated to include the symptoms of declining condition and dyspnea. In review of Record #72523 it was identified that on 12/17/2021 the patient reported pain from a fall and a physician order was received for Tramadol 50 mg every 6 hours. The POC was not updated to include the symptom of pain and treatment with Tramadol. It was further noted that the patient declined spiritual care on 11/8/2021. In review of IDG orders for 1/17/2022, the spiritual care frequency order remained 1XM 2PRN. During an interview with the Administrator, President, and the Director of Nursing on 3/31/2022 the finding was confirmed and no additional information was provided.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. 1. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by record review and interview. In 2 of 13 (15%) of records reviewed, the nursing services did not provide SN visits as directed by the POC. In review of Record #45965 it was identified this patient was admitted 6/8/2021 with a SN frequency order of 2XW. One visit was documented on 7/9/2021 for the week of 7/4/2021-7/10/2021, which did not meet the frequency orders of 2XW. In review of Record #22402 it was identified this patient was admitted 8/18/2021 with a SN frequency order of 2XW. One visit was documented on 9/16/2021 for the week of 9/12/2021-9/18/2021, which did not meet the frequency orders of 2XW. The Director of Nursing was interviewed on 3/31/2022 and confirmed that the nursing services did not provide SN visits as directed by the POC, and no additional information was provided.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: 1. The types of bereavement services to be offered; 2. The frequency of service delivery. This standard was not met as evidenced by record review and interview. 1 of 13 (8%) of records reviewed failed to provide evidence that a bereavement care plan was developed for the bereaved. In review of Record #56198, there was no documentation of a bereavement care plan developed for the bereaved of a patient that expired on 1/20/2022. In an interview with the Bereavement Coordinator on 4/1/2022, it was stated that the patient's family was contacted and bereavement services were provided, but no care plan was developed. In an interview with the Director of Nursing and the Bereavement Coordinator on 4/1/2022, it was confirmed that the bereavement care plan was not included in the clinical record and there was no additional information provided.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: 1. Noted in the plan of care; 2. Documented in the patient record, including the time spent. This standard was not met as evidenced by record review and interview. 6 of 7 (86%) of records in which the patient accepted volunteer services did not provide documentation that volunteer services were provided. In review of Record #71647, it was identified the patient requested volunteer services as indicated on the Informed Consent/Election of Benefit form signed 8/14/2021. No documentation was present in the clinical record that volunteer services were provided. In review of Record #45911, it was identified the patient requested volunteer services as indicated on the Informed Consent/Election of Benefit form signed 2/14/2021. No documentation was present in the clinical record that volunteer services were provided. In review of Record #10860, it was identified the patient requested volunteer services as indicated on the Informed Consent/Election of Benefit form signed 9/15/2021. No documentation was present in the clinical record that volunteer services were provided. In review of Record #72523, it was identified the patient requested volunteer services as indicated on the Informed Consent/Election of Benefit form signed 12/14/2021. No documentation was present in the clinical record that volunteer services were provided. In review of Record #95303, it was identified the patient requested volunteer services as indicated on the Informed Consent/Election of Benefit form signed 3/11/2022. No documentation was present in the clinical record that volunteer services were provided. In review of Record #96735, it was identified the patient requested volunteer services as indicated on the Informed Consent/Election of Benefit form signed 2/11/2022 . No documentation was present in the clinical record that volunteer services were provided. During an interview with the Administrator, President, and the Director of Nursing on 3/31/2022 the finding was confirmed and no additional information was provided.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by review of the Volunteer Program and interview with the Volunteer Coordinator. The hospice was not able to provide documentation of a viable and ongoing effort to recruit and retain volunteers. In an interview with the Volunteer Coordinator on 4/1/2022, it was confirmed that the Volunteer Coordinator had only been in the position for a short period of time and one flyer was provided in which the hospice had produced to advertise for hospice volunteers. No additional information was provided.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: 1. The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; 2. Signed copies of the notice of patient rights and the hospice election statement; 3. Responses to medications, symptom management, treatments, and services; 4. Outcome measure data elements per regulation; 5. Physician certification and recertification of terminal illness as required; 6. Any advance directives; 7. Copies of inpatient discharge summary, as applicable; 8. Physician orders. This standard was not met as evidenced by review of records and interview. 1 of 13 (8%) of records failed to provide documentation of a physician order for a catheter. In review of Record #45965 it was identified in the RN initial comprehensive assessment dated 6/8/2021 that the patient had a 16 Fr Foley catheter with a 30cc balloon placed on 5/20/2021. In review of the record on 3/31/2022, it was noted that the RN documented that the patient now had a suprapubic catheter. No physician orders for the Foley catheter or suprapubic catheter were present in the record. In an interview with the Director of Nursing it was confirmed that the patient had a suprapubic catheter and no physician orders were present to provide for the care of the catheter.

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. 1. 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. 2. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. 3. All hospice care is provided in the facility in accordance with the hospice plan of care. 4. Any changes to the hospice plan of care are discussed with the patient or representative and SNF/NF or ICF/IDF representatives, and are approved by the hospice before implementation. This standard was not met as evidenced by review of records, observation and interview. In 3 of 4 (75%) records in which the patient resided in a SNF, there was no documentation that the hospice plan of care specified which provider was responsible for performing the functions that were agreed upon based upon the needs of the patient. Record #66624 was reviewed and it was identified this patient resided in a SNF. The POC did not include which provider was responsible for performing the functions that were agreed upon based upon the needs of the patient. Record #72523 was reviewed and it was identified this patient resided in a SNF. The POC did not include which provider was responsible for performing the functions that were agreed upon based upon the needs of the patient. Record #22402 was reviewed and it was identified this patient resided in a SNF. The POC did not include which provider was responsible for performing the functions that were agreed upon based upon the needs of the patient. The Director of Nursing was interviewed on 3/31/2022 and confirmed the finding with no additional information provided.