Every finding on record at Unity Hospice, LLC

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, document review, and interview. In 12 of 12 (100%) clinical records reviewed, revealed that the agency did not ensure that each patient's individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. The agency policy 1-014, Comprehensive Assessment, dated 7/20/23, stated in part, "During the comprehensive assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including .... specific, individualized patient needs/problems ..." The agency policy 1-015, Ongoing Comprehensive Assessment, dated 7/20/23, stated in part, "...the plan of care - including problems, needs, goals, and outcomes - will be reviewed and updated by the interdisciplinary group members responsible for the case." The agency policy 1-019, Psychosocial Assessment, dated 7/20/23, stated in part, "...issues identified related to patient coping will be included in the comprehensive assessment and addressed in the plan of care and will include at least access to adequate and accurate information, change in family roles communication abilities..." Clinical Record 1: The patient elected the hospice benefit on 2/13/23. For the benefit period dated 8/12/23 - 10/10/23, the Plan of Care (POC) documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain specific problems/needs, or planned interventions. Clinical Record 2: The patient elected the hospice benefit on 4/24/23. For the benefit period dated 7/23/23 - 10/20/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain specific problems/needs, or planned interventions. Clinical Record 3: The patient elected the hospice benefit on 5/15/23. For the benefit period dated 8/13/23 - 11/20/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain specific problems/needs, or planned interventions. Clinical Record 4: The patient elected the hospice benefit on 5/18/23. For the benefit period dated 8/16/23 - 11/13/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain specific problems/needs, or planned interventions. Clinical Record 5: The patient elected the hospice benefit on 6/5/23. For the benefit period dated 9/3/23 - 12/1/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain specific problems/needs, or planned interventions. Clinical Record 6: The patient elected the hospice benefit on 10/28/22. For the benefit period dated 4/26/23 - 6/24/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain-specific problems/needs, or planned interventions. Clinical Record 7: The patient elected the hospice benefit on 11/18/22. For the benefit period dated 5/11/23 - 7/9/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain specific problems/needs, or planned interventions. Clinical Record 8: The patient elected the hospice benefit on 12/14/22. For the benefit period dated 3/16/23 - 6/12/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain-specific problems/needs, or planned interventions. Clinical Record 11: The patient elected the hospice benefit on 6/12/23. For the benefit period dated 6/12/23 - 9/10/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain specific problems/needs, or planned interventions. Clinical Record 12: The patient elected the hospice benefit on 7/6/23. For the benefit period dated 7/6/23 - 10/3/23, the POC documented social worker and chaplain visits three to four times a month. However, there were no identified psychosocial or chaplain specific problems/needs, or no planned interventions. During an interview on 10/12/23, the Director of Patient Services confirmed the finding, and stated the nurse developed the plan of care on admission, and the social worker and chaplain did not add any identified issues or interventions.

It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review, and interview. In 12 of 12 (100%) clinical records reviewed, it was revealed that the agency did not ensure the plan of care included a detailed statement of the scope and frequency of services. The agency policy 9-017, The Plan of Care, dated 7/20/2023, stated in part, "The plan of care will identify the patient's needs and services to meet those needs...it must state, in detail, the scope and frequency of services needed ..." The agency policy 1-035, Interdisciplinary Group Coordination of Care, dated 7/20/23, stated in part, "The type and scope of services provided by the interdisciplinary group will be based on the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver ...the exact combination of services...will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice." Clinical Record 1: The patient elected the hospice benefit on 2/13/23. The Plan of Care (POC) for the benefit period dated 8/12/23 - 10/10/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 2: The patient elected the hospice benefit on 4/24/23. The POC for the benefit period dated 7/23/23 - 10/20/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 3: The patient elected the hospice benefit on 5/15/23. The POC for the benefit period dated 8/13/23 - 11/20/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 4: The patient elected the hospice benefit on 5/18/2023. The POC for the benefit period 8/16/23 - 11/13/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 5: The patient elected the hospice benefit on 6/5/23. The POC for the benefit period dated 9/3/23 - 12/1/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 6: The patient elected the hospice benefit on 10/28/22. The POC for the benefit period dated 4/26/23 - 6/24/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 7: The patient elected the hospice benefit on 11/18/22. The POC for the benefit period dated 5/11/23 - 7/9/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 8: The patient elected the hospice benefit on 12/14/22. The POC for the benefit period dated 3/16/23 - 6/12/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 9: The patient elected the hospice benefit on 1/27/23. The POC for the benefit period dated 1/27/23 - 4/27/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 10: The patient elected the hospice benefit on 3/12/23. The POC for the benefit period dated 3/12/23 - 6/11/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 11: The patient elected the hospice benefit on 6/12/23. The POC for the benefit period dated 6/12/23 - 9/10/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. Clinical Record 12: The patient elected the hospice benefit on 7/6/23. The POC for the benefit period dated 7/6/23 - 10/3/23, documented PRN orders for every discipline. However, there was no direction or indication of use for the PRN (as needed) frequency. the number or reason for the PRN visits indicated. There were also PRN orders for the Hospice Aide included. During an interview on 10/11/23, the Director of Clinical Services confirmed the finding, and stated that she was unaware PRN visits needed to be individualized to the patient needs, and document a reason for use.

The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, social and emotional factors related to the terminal illness, presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, family support systems to facilitate coping with end-of-life issues. This standard was not met as evidenced by clinical record review, document review, and interview. In 11 of 12 (92%) clinical records reviewed, it was revealed that the agency did not ensure the required components of the psychosocial assessment were completed by the Social Worker (SW). The agency policy 1-019, Psychosocial Assessment, dated 7/20/23, stated in part, "Psychosocial assessment will be completed by a qualified hospice social worker or registered nurse. The assessment includes but is not limited to coping with and adjusting to the patient's terminal illness, making final arrangements, reaction to the terminal illness, and bereavement needs...A psychosocial assessment will be performed at the initial meeting of the patient and family/caregiver. The psychosocial assessment will include but not be limited to an evaluation of the patient's preferred style of communication, including expressing emotions, feelings, thoughts, and needs; the patient's and family's attitude and emotional response to the terminal illness and treatment interventions; the patient and family/caregiver identification of drug and alcohol history; a scale of psychosocial support; a scale of coping styles and impact of illness on certain physical functions; family dynamics and communication patterns; obstacles and risk factors that may affect compliance with the plan of care; family support systems to facilitate coping with end of life issues; need for volunteer services to offer support or respite to the patient and family/caregiver; financial assessment; a bereavement risk assessment ..." Clinical Record 1: The patient elected the hospice benefit on 2/13/23. The initial assessment was completed by the Social Worker on 2/13/23. The Social Worker did not address the following required components of the psychosocial assessment: the patient’s and the family’s adjustment to the terminal illness; social and emotional factors related to the terminal illness; presence or absence of adequate coping mechanisms; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care (POC). Clinical Record 2: The patient elected the hospice benefit on 4/24/23. On 7/12/23, 7/18/23, 7/25/23, and 8/3/23, the Social Worker documented interaction with the patient. The Social Worker did not address the following required components of the psychosocial assessment: the patient’s and the family’s adjustment to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the POC. Clinical Record 3: The patient elected the hospice benefit on 5/15/2023. On 8/8/23, 8/22/23, and 9/12/23, the Social Worker documented interaction with the patient. The Social Worker did not address the following required components of the psychosocial assessment: the patient’s and the family’s adjustment to the terminal illness; social and emotional factors related to the terminal illness; presence or absence of adequate coping mechanisms; family dynamics, and communication patterns; financial resources and any constraints; caregiver’s ability to function effectively; obstacles and risk factors that may affect compliance with the POC; and family support systems to facilitate coping with end-of-life issues. Clinical Record 4: The patient elected the hospice benefit on 5/18/23. On 5/18/23, the Social Worker documented the initial assessment. The Social Worker did not address the following required components of the psychosocial assessment: the patient’s and the family’s adjustment to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; caregiver’s ability to function effectively; and obstacles/risk factors that may affect compliance with the POC. Clinical Record 6: The patient elected the hospice benefit on 10/28/22. On 10/28/22, the Social Worker documented the initial assessment. The Social Worker did not address the following required components of the psychosocial assessment: the patient’s and the family’s adjustment to the terminal illness; social and emotional factors related to the terminal illness; presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraint; caregiver’s ability to function effectively; obstacles and risk factors that may affect compliance with the plan of care; or family support systems to facilitate coping with end-of-life issues. Clinical Record 7: The patient elected the hospice benefit on 11/18/22. On 11/22/22, the Social Worker documented the initial assessment. The Social Worker did not address the following required components of the psychosocial assessment: the patient’s and the family’s adjustment to the terminal illness; social and emotional factors related to the terminal illness; presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; caregiver’s ability to function effectively; and obstacles/risk factors that may affect compliance with the POC. Clinical Record 8: The patient elected the hospice benefit on 12/14/22. On 12/16/22, the Social Worker documented the initial assessment. The Social Worker did not address the following required components of the psychosocial assessment: the social and emotional factors related to the terminal illness; presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles/risk factors that may affect compliance with the POC. Clinical Record 9: The patient elected the hospice benefit on 1/27/23. On 1/30/23, the Social Worker documented the initial assessment. The Social Worker did not address the following required components of the psychosocial assessment: financial resources and any constraints or obstacles; and risk factors that may affect compliance with the POC. Clinical Record 10: The patient elected the hospice benefit on 3/12/23. On 3/16/23, the Social Worker documented the initial assessment. The Social Worker did not address the following required components of the psychosocial assessment: financial resources and any constraints; the caregiver’s ability to function effectively; obstacles and risk factors that may affect compliance with the POC; and family support systems to facilitate coping with end-of-life issues. Clinical Record 11: The patient elected the hospice benefit on 6/12/23. On 6/22/23, the Social Worker documented the initial assessment. The Social Worker did not address the following required components of the psychosocial assessment: the patient’s and the family’s adjustment to the terminal illness; social and emotional factors related to the terminal illness; presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; caregiver’s ability to function effectively; obstacles and risk factors that may affect compliance with the POC; and family support systems to facilitate coping with end-of-life issues. Clinical Record 12: The patient elected the hospice benefit on 7/6/23. On 7/11/23, the Social Worker documented the initial assessment. The Social Worker did not address the following required areas of the psychosocial assessment: adjustment to the terminal illness; social and emotional factors related to the terminal illness; presence or absence of adequate coping mechanisms; family dynamics and communication pattern; financial resources and any constraints; caregiver’s ability to function effectively; obstacles and risk factors that may affect compliance with the POC; and family support systems to facilitate coping with end-of-life issues. During an interview on 10/12/23, the Director of Patient Services confirmed the finding, and stated there was no format for the Social Worker assessment to include the required elements.

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, document review, and interview. In 7 of 7 (100%) clinical records reviewed, it was revealed that the agency did not ensure a bereavement plan of care (POPC) was developed and documented for the family/caregivers of the patient. The agency policy 9-023, Bereavement Services, dated 7/20/23, stated in part, "A bereavement risk assessment will be completed ...at the time of admission. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care...After a death has occurred, the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. Bereavement interventions will be reflective of the family/caregiver's choices to participate in the bereavement program...A bereavement file will be maintained on each family/caregiver ...each file will contain. a copy of the patient referral and initial bereavement assessment...all bereavement assessments made, a bereavement plan of care, all bereavement clinical notes that have been written and/or letters sent to the bereaved." Clinical Record 6: The patient elected the hospice benefit on 5/2/23 and subsequently died on 7/5/23. There was a post-death bereavement assessment documented which included: patient's name; date of death; and contact name, relationship to the patient, address, phone number, and email address. However, there was no indication of the services or the frequency of services to be provided by the hospice. Clinical Record 7: The patient elected the hospice benefit on 11/18/22 and subsequently died on 5/23/23. There was a post-death bereavement assessment documented which included: patient's name; date of death; and contact's name, relationship to the patient, address, phone number, and email address. However, there was no indication of the services or the frequency of services to be provided by the hospice. Clinical Record 8: The patient elected the hospice benefit on 12/14/22 and subsequently died on 3/21/23. There was a post-death bereavement assessment documented which included: patient's name; date of death; and contact's name, relationship to the patient, address, phone number, and email address. However, there was no indication of the services or the frequency of services to be provided by the hospice. Clinical Record 9: The patient elected the hospice benefit on 1/27/23 and subsequently died on 2/2/23. There was a post-death bereavement assessment documented which included: patient's name; date of death; and contact's name; relationship to the patient; address; phone number; and email address. However, there was no indication of the services or the frequency of services to be provided by the hospice. Clinical Record 10: The patient elected the hospice benefit on 3/12/23 and subsequently died on 3/17/23. There was a post-death bereavement assessment documented which included: patient's name; date of death and contact's name, relationship to the patient, address, phone number, and email address. However, there was no indication of the services or the frequency of services to be provided by the hospice. Clinical Record 11: The patient elected the hospice benefit on 6/12/23 and subsequently died on 7/5/23. There was a post-death bereavement assessment documented which included: patient's name; date of death; and contact's name, relationship to the patient, address, phone number, and email address. However, there was no indication of the services or the frequency of services to be provided by the hospice. Clinical Record 12: The patient elected the hospice benefit on 7/6/23 and subsequently died on 7/14/23. There was a post-death bereavement assessment documented which included: patient's name; date of death; and contact's name, relationship to the patient, address, phone number, and email address. However, there was no indication of the services or the frequency of services to be provided by the hospice. During an Interview on 10/11/23, the Director of Patient Services confirmed the finding, and stated she did not know this was a requirement.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and document review. In 4 of 12 (33%) clinical records reviewed, it was revealed that the agency did not ensure all entries in the patient record were legible and in accordance with hospice policy. The agency policy 6-022, Clinical/Service Data Collection, dated 7/20/23 stated in part, "Errors in documentation will be corrected ...draw a line through the entry, date, and initial. Do not erase, use correction fluid, or deface a document." Clinical Record 3: The patient elected the hospice benefit on 5/15/23. The entry by the Chaplain was dated after the 9/19/23 entry by the Social Worker. The handwritten date was written over the original date, but was not legible. This was not compliant with agency policy. Clinical Record 6: The patient elected the hospice benefit on 10/28/22. The entry by the Social Worker dated 4/6/23, was crossed through with a big "X," and "error wrong chart" was written. This was not compliant with agency policy. Clinical Record 7: The patient elected the hospice benefit on 11/18/22. The Interdisciplinary Group Meeting was dated 4/13/23. The frequency of visits for the social worker and chaplain were changed using white out. The frequency was changed to "3 - 4 x mo." This was not compliant with agency policy. Clinical Record 10: The patient elected the hospice benefit on 3/12/23. The entry by the Social Worker was dated 3/15/23. The handwritten date was written over the original date, but was not legible. This was not compliant per agency policy. During an interview on 10/12/23, the Director of Patient Services confirmed the finding, and stated that the expectation was for errors to be corrected per policy.

CONDITION OF PARTICIPATION: 418.113 EMERGENCY PREPAREDNESS. It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff and patient population, with attention to their mobility and describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of policy and procedure revealed the hospice failed to maintain a written comprehensive emergency preparedness program. The organization failed to do the following: 418.113(a) Develop and maintain an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. The plan: is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served; includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of: power failures; natural or man-made disasters; emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk; and other anticipated emergencies that could affect the hospice’s ability to provide care; addresses the patient population served, specifically: the care and safety of patients with limited mobility; and those requiring evacuation due to a medical or psychiatric condition, or their home environment; addresses when emergency preparedness officials are contacted regarding evacuation of patients; defines the type of care and services the hospice can provide in an emergency; addresses continuity of business functions essential to operations, including identification of staff or positions that can assume key organization roles if current staff and leadership are not available; and includes a process for cooperation and collaboration with local, tribal, regional, state, or federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency; 418.113(b) Implement emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: 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; the documented discussion of the plan provided to the patient/family, and maintained by the hospice; follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency; arrangements with facilities and other providers to receive patients to maintain the continuity of care to patients; informing local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency based on the patient’s medical or psychiatric condition, or home environment; the minimum information provided to facilitate patient evacuation and transportation including: if the patient is mobile or not; if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). A system of medical documentation that preserves patient information, protects the confidentiality of patient information, and secures and maintains the availability of records; informing local and state emergency officials of any on-duty employees that the hospice is unable to contact; the role of hospice employees in providing care at alternate care sites during emergencies; and the use of volunteers, off-duty hospice employees and other emergency staffing strategies, including the process and role for the integration of state and federally designated health care professionals to address surge patient care needs during an emergency. Policies and procedures are reviewed and updated at least every two (2) years; 418.113(c) Maintain an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes: names and contact information for hospice employees, patients’ physicians, entities providing services under arrangement, and other hospices; contact information for the federal, state, tribal, regional, local emergency preparedness staff, and other sources of assistance; primary and alternate means for communicating with hospice staff, federal, state, tribal, regional, and local emergency management agencies; how information and medical documentation for patients under the hospice’s care is shared, as necessary, with other healthcare providers to maintain the continuity of care; information in the event of an evacuation concerning how to release patient information, including their general condition and location, as permitted by the Health Insurance Portability and Accountability Act (HIPAA). The communication plan, including all contact information, is reviewed and updated at least every two (2) years; and 418.113(d) Maintain an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. The cumulative effect of these deficient practices may pose a risk to patient safety and has resulted in a Condition Level finding under CFR 418.113 Emergency Preparedness. During review of agency policies and procedures it was revealed that the agency had not ensured that they had developed a written comprehensive emergency preparedness (EP) plan that demonstrated compliance with applicable federal, state, and local emergency preparedness requirements, used an “all hazards” approach, described the hospice’s approach to meeting the health, safety, and security of the staff and patient population, with attention to their mobility and described how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. Review of the agency policy titled "Hospice Emergency Preparedness Plan" dated 6/8/23 lacked evidence that the agency had developed a written comprehensive emergency preparedness plan that demonstrated compliance with applicable federal, state, and local emergency preparedness requirements, used an “all hazards” approach, described the hospice’s approach to meeting the health, safety, and security of the staff and patient population, with attention to their mobility and described how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. The policy did state in relevant parts, " a/b The Emergency Preparedness Plan for patients and staff of (hospice name) will follow the (Assisted Living Facility (ALF) name) Emergency Preparedness Plan as approved by the Fire Department. Patients of (hospice name) are residents of the (ALF name), so the responsibility is shared". The ALF is owned by the same entity as the hospice but is not a Medicare certified facility. In an interview and joint policy review conducted with the Director of Clinical Services (DCS)/Administrator on 6/29/23 they did state that the agency had not developed a comprehensive written Emergency Preparedness (EP) Plan for the hospice that demonstrated compliance with applicable federal, state, and local emergency preparedness requirements, that used an “all hazards” approach, described the hospice’s approach to meeting the health, safety, and security of staff, and patient population, and included how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. The DCS stated that the agency's EP plan was to follow the EP plan of the ALF as they are owned by the same entity and 100% of their patients reside in the ALF.

It is required that the patient’s pain is assessed as part of a comprehensive assessment and the documented assessment of the patient’s pain includes use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, including, location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping) and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. In 10 of 11 (91%) clinical records reviewed the agency did not ensure that as part of a comprehensive assessment the patient's pain was assessed using a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status that included, location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping) and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. Clinical Record 1: The patient elected the hospice benefit on 2/13/23. For the benefit period dated 2/13/23 to 5/13/23, there was no evidence that the comprehensive assessment dated 2/13/23, included an assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 2: The patient elected the hospice benefit on 4/24/23. For the benefit period dated 4/24/23 to 7/22/23, there was no evidence that the comprehensive assessment dated 4/24/23, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 3: The patient elected the hospice benefit on 5/15/23. For the benefit period dated 5/15/23 to 8/14/23, there was no evidence that the comprehensive assessment dated 5/15/23, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 4: The patient elected the hospice benefit on 5/17/23. For the benefit period dated 5/17/23 to 8/16/23, there was no evidence that the comprehensive assessment dated 5/17/23, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 6: The patient elected the hospice benefit on 6/12/23. For the benefit period dated 6/12/23 to 9/10/23, there was no evidence that the comprehensive assessment dated 6/12/23, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 7: The patient elected the hospice benefit on 10/28/22. For the benefit period dated 10/28/22 to 1/26/23, there was no evidence that the comprehensive assessment dated 10/28/22, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 8: The patient elected the hospice benefit on 11/18/22. For the benefit period dated 11/18/22 to 2/14/23, there was no evidence that the comprehensive assessment dated 11/28/22, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 9: The patient elected the hospice benefit on 12/14/22. For the benefit period dated 12/14/22 to 3/15/23, there was no evidence that the comprehensive assessment dated 12/14/22, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 10: The patient elected the hospice benefit on 1/27/23. For the benefit period dated 1/27/23 to 4/27/23, there was no evidence that the comprehensive assessment dated 1/27/23, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. Clinical Record 11: The patient elected the hospice benefit on 3/12/23. For the benefit period dated 3/12/23 to 6/9/23, there was no evidence that the comprehensive assessment dated 3/12/23, included assessment of the patient’s pain using a standardized pain assessment tool, appropriate to the patient’s developmental and cognitive status. During a joint clinical record review and interview on 6/30/23, the Administrator/Director of Clinical Services confirmed the findings.

It is required that the comprehensive assessment includes data elements that allow for the measurement of outcomes. This standard was not met as evidenced by clinical record review and interview. In 11 of 11 (100%) clinical records reviewed, it was revealed that the agency did not ensure the comprehensive assessment included data elements that allowed for the measurement of outcomes. During review of clinical records, there was no evidence that the comprehensive assessment included data elements that allowed for the measurement of outcomes. The evidence included: Clinical Record 1: Start of care (SOC) 2/13/23. Benefit period (BP) 2/13/23 to 5/13/23; Clinical Record 2: SOC 4/24/23. BP 4/24/23 to 7/22/23; Clinical Record 3: SOC 5/15/23. BP 5/15/23 to 8/14/23; Clinical Record 4: SOC 5/17/23. BP 5/17/22 to 8/16/23; Clinical Record 5: SOC 6/5/23. BP 6/5/23 to 9/3/23; Clinical Record 6: SOC 6/12/23. BP 6/12/23 to 9/10/23: Clinical Record 7: SOC 10/28/22. BP 10/28/22 to 1/26/23; Clinical Record 8: SOC 11/18/22. BP 1/18/22 to 2/14/23: Clinical Record 9: SOC 12/14/22. BP 12/14/22 to 3/15/23; Clinical Record 10: SOC 1/27/23. BP 1/27/23 to 4/27/23; and Clinical Record 11: SOC 3/12/23. BP 3/12/23 to 6/9/23. During a joint clinical record review and interview on 6/30/23, the Administrator/Director of Clinical Services confirmed the finding. In a review of all clinical records it was revealed there was a lack of evidence that the comprehensive assessment included data elements that allowed for the measurement of outcomes. This includes record 1; start of care (SOC), 2/13/23, benefit period (BP) dated 2/13/23 to 5/13/23; record 2, SOC: 4/24/23, BP dated, 4/24/23 to 7/22/23; record 3, SOC: 5/15/23, BP dated, 5/15/23 to 8/14/23; record 4, SOC: 5/17/23, BP dated, 5/17/22 to 8/16/23; record 5, SOC: 6/5/23, BP dated, 6/5/23 to 9/3/23, record 6, SOC: 6/12/23, BP dated, 6/12/23 to 9/10/23: record 7, SOC: 10/28/22, BP dated, 10/28/22 to 1/26/23; record 8, SOC: 11/18/22, BP dated, 11/18/22 to 2/14/23: record 9, SOC: 12/14/22, BP dated, 12/14/22 to 3/15/23; record 10, SOC: 1/27/23, BP dated, 1/27/23 to 4/27/23 and record 11, SOC: 3/12/23, BP dated, 3/12/23 to 6/9/23. In an interview and joint clinical record review with the Director of Clinical Services (DCS) conducted on 6/30/23 they did verify that the agency did not collect measurable data elements as part of the comprehensive assessment and had no policies or procedures in place to ensure this data collection was conducted. The DCS did state that the agency did not use a standardized tool to collect data when completing the comprehensive assessment.

It is required that the hospice documents and maintains an effective infection control program that includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by clinical record review, document review, personnel record review, and interview. In 11 of 11 (100%) clinical records reviewed, the agency did not ensure that education of infection control was provided to patients, families and other caregivers. In 5 of 8 (62%) personnel records reviewed, the agency did not ensure that education of infection control was provided to employees and contracted providers. Agency policy, Infection Control, did not include education on infection control provided to employees, contracted providers, patients, families, and other caregivers. A review of clinical records revealed there was no evidence that infection control education was provided to patients, family members, and other caregivers. The evidence includes: Clinical Record 1: Start of care (SOC) 2/13/23, benefit period (BP) dated 2/13/23 to 5/13/23; Clinical Record 2: SOC 4/24/23, BP 4/24/23 to 7/22/23; Clinical Record 3: SOC 5/15/23, BP 5/15/23 to 8/14/23; Clinical Record 4: SOC 5/17/23, BP 5/17/22 to 8/16/23; Clinical Record 5: SOC 6/5/23, BP 6/5/23 to 9/3/23; Clinical Record 6: SOC 6/12/23, BP 6/12/23 to 9/10/23; Clinical Record 7: SOC 10/28/22, BP 10/28/22 to 1/26/23; Clinical Record 8: SOC 11/18/22, BP 11/18/22 to 2/14/23; Clinical Record 9: SOC 12/14/22, BP 12/14/22 to 3/15/23; Clinical Record 10: SOC 1/27/23, BP 1/27/23 to 4/27/23; and Clinical Record 11: SOC 3/12/23, BP 3/12/23 to 6/9/23. A review of personnel records revealed there was no evidence that infection control education was provided to employees and contracted providers. The evidence includes: Personnel Record 1: Medical Director with date of hire (DOH) 11/14/22; Personnel Record 2: Director of Clinical Services with DOH 9/14/22; Personnel Record 3: Social worker with DOH 3/6/23; Personnel Record 4: Chaplain with DOH 11/10/22; Personnel Record 7: Medical Director with DOH 11/14/22. During a joint record review and interview on 6/30/23, the Administrator/ Director of Clinical Services confirmed the findings. In a review of all clinical records, it was revealed there was a lack of evidence that infection control education was provided to patients, family members, and other caregivers. This includes record 1; start of care (SOC), 2/13/23, benefit period (BP) dated 2/13/23 to 5/13/23; record 2, SOC: 4/24/23, BP dated, 4/24/23 to 7/22/23; record 3, SOC: 5/15/23, BP dated, 5/15/23 to 8/14/23; record 4, SOC: 5/17/23, BP dated, 5/17/22 to 8/16/23; record 5, SOC: 6/5/23, BP dated, 6/5/23 to 9/3/23, record 6, SOC: 6/12/23, BP dated, 6/12/23 to 9/10/23: record 7, SOC: 10/28/22, BP dated, 10/28/22 to 1/26/23; record 8, SOC: 11/18/22, BP dated, 11/18/22 to 2/14/23: record 9, SOC: 12/14/22, BP dated, 12/14/22 to 3/15/23; record 10, SOC: 1/27/23, BP dated, 1/27/23 to 4/27/23 and record 11, SOC: 3/12/23, BP dated, 3/12/23 to 6/9/23.

CONDITION OF PARTICIPATION: 418.64 CORE SERVICES It is required that a hospice must routinely provide substantially all core services directly by hospice employees. These services must be provided in a manner consistent with acceptable standards of practice. These services include nursing services, medical social services, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review, personnel record review, document review, and interview. Review of clinical records, personnel records, documents and interview revealed that the hospice failed to ensure that a core service was provided directly by hospice employees. The hospice failed to provide substantially all core services directly by hospice employees. Specifically, counseling services, including spiritual counseling, was not provided directly by a hospice employee. The chaplain, who provided spiritual counseling, was not a hospice employee and was not issued a W-2 form. The chaplain was a contract employee. There was no evidence of the following: the hospice used contracted staff, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances; the hospice entered into a written agreement with another Medicare certified hospice employee/staff to meet the needs of patients; and circumstances under which a hospice may enter into a written arrangement for the provision of core services. 418.64(d) The hospice failed to provide counseling services to 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. 418.64(d)(1)(i). Bereavement services were not available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling did not extend to residents of a SNF/NF, or ICF/IDF when appropriate and was not identified in the plan of care. 418.64(d)(1)(ii) The bereavement services did not reflect the needs of the bereaved per the bereavement plan of care including the following: the types of bereavement services to be offered; and the frequency of service delivery. 418.64(d)(1)(iii). 418.64(d)(1)(iv). The cumulative effect of these deficient practices may pose a risk to patient safety and has resulted in a Condition Level finding under CFR 418.64 Core Services. In all clinical records reviewed it was revealed that chaplain visits ordered by the medical director and included in the plan of care were conducted by a spiritual counselor who was contracted and not a direct employee of the hospice. The agency could provide no evidence for the need to use contracted staff, to supplement hospice employees to meet the needs of patients related to extraordinary or other non-routine circumstances. This includes record 1; start of care (SOC), 2/13/23, benefit period (BP) dated 2/13/23 to 5/13/23; record 2, SOC: 4/24/23, BP dated, 4/24/23 to 7/22/23; record 3, SOC: 5/15/23, BP dated, 5/15/23 to 8/14/23; record 4, SOC: 5/17/23, BP dated, 5/17/22 to 8/16/23; record 5, SOC: 6/5/23, BP dated, 6/5/23 to 9/3/23, record 6, SOC: 6/12/23, BP dated, 6/12/23 to 9/10/23: record 7, SOC: 10/28/22, BP dated, 10/28/22 to 1/26/23; record 8, SOC: 11/18/22, BP dated, 11/18/22 to 2/14/23: record 9, SOC: 12/14/22, BP dated, 12/14/22 to 3/15/23; record 10, SOC: 1/27/23, BP dated, 1/27/23 to 4/27/23 and record 11, SOC: 3/12/23, BP dated, 3/12/23 to 6/9/23. In an interview and joint clinical record and personnel record review conducted with the Director of Clinical Services (DCS) on 6/29/23 they did state that all patients and families had received ordered spiritual care counseling from a contracted chaplain not a direct employee of the hospice. CFR 418.64 L-588

CONDITION OF PARTICIPATION: 418.70 FURNISHING OF NON-CORE SERVICES. It is required that a hospice must ensure that “non-core” services are available and provided directly by hospice or under arrangement. The following "non-core" services are provided in a manner consistent with current standards of practice: physical therapy; occupational therapy; and speech-language pathology services. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by personnel record review, document review, and interview. Review of personnel records and agency contracts on 6/29/23, revealed the agency failed to ensure that “non-core” services were available and provided directly by hospice or under arrangement. The hospice did not have the following "non-core" services available and provided directly by hospice or under arrangement: physical therapy; occupational therapy; and speech-language pathology services. The cumulative effect of these deficient practices may pose a risk to patient safety and has resulted in a Condition Level finding under CFR 418.70 Furnishing of Non-Core Services. A review of agency contracts and personnel records conducted on 6/29/23 revealed a lack of evidence that the agency ensured that “non-core” services including physical therapy, occupational therapy, and speech-language pathology were available and provided directly by the hospice or under arrangement. In an interview with the Director of Clinical Services (DCS)/Administrator on 6/29/23 they did confirm that the agency did not have direct or contracted employees to provide non-core” services including physical therapy, occupational therapy, and speech-language pathology. CFR 418.70 L-602

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 clinical record review and interview. In 6 of 11 (55%) clinical records reviewed, the agency did not ensure the hospice aide provided services as ordered by the interdisciplinary group and included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 2/13/23. The plan of care (POC) for the benefit period dated 2/13/23 to 5/13/23, included the following: physician order dated 2/13/23, for hospice aide (HA) visits "3 times a week," through 5/13/23. For the weeks of 2/26/23 to 3/4/23 and 4/16/23 to 4/22/23, only 2 HA visits were completed per week. For the weeks of 6/11/23 to 6/24/23, only 1 HA visit was completed per week. There was no evidence of documented missed hospice aide visits, or communication with the physician to change the visit frequency. Clinical Record 2: The patient elected the hospice benefit on 4/24/23. The POC for the benefit period dated 4/24/23 to 7/22/23, included the following: physician order dated 4/24/23, for hospice aide (HA) visits "3 times a week," through 7/22/23. For the week of 4/30/23 to 5/6/23, only 2 HA visits were completed. For the week of 6/11/23 to 6/17/23, only 1 HA visit was completed. There was no evidence of documented missed hospice aide visits, or communication with the physician to change the visit frequency. Clinical Record 3: The patient elected the hospice benefit on 5/15/23. The POC for the benefit period dated 5/15/23 to 8/14/23/23, included the following: physician order dated 5/15/23, for hospice aide (HA) visits "3 times a week," through 5/13/23. For the week of 6/11/23 to 6/17/23, only 1 HA visit was completed. There was no evidence of documented missed hospice aide visits, or communication with the physician to change the visit frequency. Clinical Record 7: The patient elected the hospice benefit on 10/28/22. The POC for the benefit period dated 10/28/22 to 1/26/23, included the following: physician order dated 12/5/22, for hospice aide (HA) visits "3 times a week," through 1/26/23. For the weeks of 12/11/23 to 12/24/23, only 2 HA visits were completed per week. For the week of 1/15/23 to 1/21/23, no HA visits were completed. There was no evidence of documented missed hospice aide visits, or communication with the physician to change the visit frequency. Clinical Record 8: The patient elected the hospice benefit on 11/18/22. The POC for the benefit period dated 11/18/22 to 2/14/23, included the following: physician order dated 11/23/22, for hospice aide (HA) visits "3 times a week," through 2/14/23. For the weeks of 11/23/22 to 12/3/22 and 1/15/22 to 1/28/22, no HA visits were completed. For the weeks of 12/11/22 to 12/31/22 and 1/8/23 to 1/14/23, only 1 visit was completed per week. There was no evidence of documented missed hospice aide visits, or communication with the physician to change the visit frequency. Clinical Record 9: The patient elected the hospice benefit on 12/14/22. The POC for the benefit period dated 12/14/22 to 3/15/23, included the following: physician order dated 12/14/22, for hospice aide (HA) visits "3 times a week," through 3/15/23. For the weeks of 12/18/22 through 12/31/22, only 1 HA visit was completed per week. For the week dated 1/8/23 to 1/14/23, only 2 HA visits were completed. For the weeks of 1/15/23 to 1/21/23, no HA visits were completed. There was no evidence of documented missed hospice aide visits, or communication with the physician to change the visit frequency. During a joint clinical record review and interview on 6/30/23, the Administrator/Director of Clinical Services confirmed the findings.

It is required that the hospice provides orientation on hospice philosophy to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by interview and personnel record review. In 5 of 8 (62%) personnel records reviewed, it was revealed that the agency did not ensure that orientation on hospice philosophy was provided to all employees and contracted staff who had patient and family contact. Personnel Record 1: A review of the personnel record on 6/30/23, for the Medical Director with date of hire (DOH) 11/14/22, revealed there was no evidence that orientation on hospice philosophy was provided. Personnel Record 2: A review of the personnel record on 6/30/23, for the Director of Clinical Services (DCS) with DOH 9/14/22, revealed there was no evidence that orientation on hospice philosophy was provided. Personnel Record 3: A review of the personnel record on 6/30/23, for the Social Worker with DOH 3/6/23, revealed there was no evidence that orientation on hospice philosophy was provided. Personnel Record 4: A review of the personnel record on 6/30/23, for the Chaplain with DOH 11/10/22, revealed there was no evidence that orientation on hospice philosophy was provided. Personnel Record 7: A review of the personnel file on 6/30/23, for the Associate Medical Director with DOH 11/14/22, revealed there was no evidence that orientation on hospice philosophy was provided. During a joint personnel record review and interview on 6/30/23, the Administrator/Director of Clinical Services confirmed the findings.

CONDITION OF PARTICIPATION 418.108 SHORT-TERM INPATIENT CARE. It is required that short-term inpatient care is available for pain control, symptom management, and respite purposes. The hospice has criteria for general inpatient care and for respite admissions. Inpatient care is provided in a participating Medicare or Medicaid facility. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by document review and interview. Review of agency documents revealed that the hospice failed to ensure that short-term inpatient care was available for pain control, symptom management, and respite purposes. The hospice failed to ensure the following: inpatient care was available for pain control, symptom management, and respite purposes, and must be provided in a participating Medicare or Medicaid facility (418.108); inpatient care for symptom management and pain control (418.108(a)); must be provided in one of the following: a Medicare-certified hospice that meets the conditions of participation for providing inpatient care directly as specified in 418.110 (418.108(a)(1)); Medicare-certified hospital or a skilled nursing facility that also meets the standards specified in 418.110(b) and (f) regarding 24-hour nursing services and patient areas (418.108(a)(2)); Inpatient care for respite purposes (418.108(b)); a Medicare or Medicaid-certified nursing facility that also meets the standards specified in 418.110(f) (418.108(b)(1)(ii); the facility providing respite care must provide 24-hour nursing services that meet the nursing needs of all patients and are furnished in accordance with each patient's plan of care (418.108(b)(2)); Inpatient care provided under arrangements (418.108(c)); the inpatient provider has established patient care policies (418.108(c)(2)); the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility (418.108(c)(3)); the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement (418.108(c)(4); the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided (418.108(c)(5)); a method for verifying that the requirements are met (418.108(c)(6)); the total number of inpatient days used by Medicare beneficiaries who elected hospice coverage in a 12-month period in a particular hospice may not exceed 20 percent of the total number of hospice days consumed in total by this group of beneficiaries (418.108(d)). The cumulative effect of these deficient practices may pose a risk to patient safety and has resulted in a Condition Level finding under CFR 418.108 Short-term Inpatient Care. In an interview with the Director Clinical Services (DCS) conducted on 6/28/23 they did state that the agency did not have a contract with a Medicare certified facility to provide short-term inpatient care for pain control, symptom management, and respite purposes. They did further state that they thought they could provide those services if required in the assisted living facility (ALF) where 100% of their patients reside. The ALF which is owned by the same entity as the hospice is not a Medicare certified facility. In a joint review of agency policies and procedures conducted with the DCS on 6/28/23 the DCS did state that the agency had not developed criteria for general inpatient care and for respite admissions.