Every finding on record at Universal Health Net

Based on interview and record review, the hospice failed to ensure the emergency preparedness risk assessment plan included specific information that the hospice may reasonably expect to confront, creating the increased risk of not addressing the care needs for the patients during an emergency. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The Hazard Vulnerability Assessment dated 1/2/23, showed a list of different events such as fire, flooding, earthquake, electrical failure, and hostage situation. Documentation showed these events had a corresponding number for probability, level of vulnerability, and preparedness; and each event had a total score. However, there was no documented evidence on what the total score/values meant or what the total score/values may need. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan addressed the patient population including, but not limited to, persons at-risk; the type of services the hospice has the ability to provide in an emergency; and continuity of operations including delegations of authority and succession plans. This created the risk not providing appropriate, consistent and quality care to the patients. --- Findings: a. Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not address the patient population including, but not limited to, persons at-risk; the type of services the hospice had the ability to provide in an emergency. b. In addition, review of the hospice's emergency preparedness plan and P&P for emergency management plan showed the continuity of operations including the delegation of authority was not consistent. The Emergency Preparedness Plan, undated, showed the Director who serve as the Incident Commander had the authority to activate and deactivate the emergency preparedness plan. If the Director is not available, the Assistant Director, and then the Chief Clinical Officer will have the authority to activate the response plan. However, the P&P titled Emergency Management Plan dated 5/22 showed the Executive Director/Administrator or designee has been designated as key leadership who is responsible for all emergency activities and makes the decision to implement the emergency plan upon becoming aware of an emergency structure. The Executive Director/Administrator and key leadership will determine the leadership command structure to ensure continuity of operation. The Command Structure showed the hospices organizational chart. The organizational chart showed the President/CEO on top of the grid and goes down to the Administrator and DPCS; under the Administrator was the Medical Director; and under the DPCS was the DPCS Designee. The All-Hazard Command Structure undated showed the command structure include the Administrator, DPCS, Bereavement, Volunteer Coordinator, and Team Coordinator in that order. The Hospice Administrator is responsible for activating the hospice emergency management plan. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included the process for cooperation and collaboration with the local, regional, State, and Federal emergency preparedness officials efforts to maintain an integrated response during a disaster or emergency. This failure created the risk of not providing the necessary care and services to the patients of the hospice during an emergency. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not include a process for cooperation and collaboration with the local, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included the procedures to inform the State and local officials in the event the hospice was unable to contact of any on duty staff and patients during an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not include the procedures to inform the State and local officials of any on-duty staff or patients that they are unable to contact during an emergency. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included the procedures to inform State and local emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not include on the procedures on informing the State and local emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included procedures for other emergency staffing strategies including the process and role of integration of the State and Federally designated healthcare professionals to address the surge needs during an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency in the event the hospice and local agencies resources were exhausted. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not include procedures on how the hospice would use other emergency staffing strategies including the process and role of integrating the State and Federally designated health care professionals to address surge needs during an emergency. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan addressed the development of arrangements with other facilities and other providers to receive the patients in the event of limitations or cessation of operations to maintain the continuity to the hospice patients. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not include the development of arrangements with other facilities and providers to receive the patients in the event of limitations or cessation of operations to maintain the continuity to the patients. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness hospice communication plan included the names and contact information of the hospice staff, contractors, physicians, and other hospices. This failure created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not include the contact information for the names and contact information of the hospice staff, contractors, physicians, and other hospices. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness communication plan included the contact information of the State. This failure created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not include the contact information for the State. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness communication plan included the method for sharing information and medical documentation for the patients with other health providers to maintain the continuity of care and means of providing information about the general condition and location of the patients under the hospice's care. This failure created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents failed to include the method for sharing information and medical documentation for the patients with other health providers to maintain the continuity of care and means of providing information about the general condition and location of the patients under the hospice's care. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on record review and interview, the agency failed to ensure the initial training in the emergency preparedness P&P was provided for HA 1. In addition, the agency failed to ensure the trainings were recorded and maintained. These failures created the risk of the hospice's staff not knowing what to do in case of an emergency. --- Findings: 1. Review of the hospices emergency preparedness program documents was initiated on 11/16/23. a. Review of the employee file for HA 1 was initiated on 11/21/23. HA 1 was hired on 10/13/23. However, there was no documented evidence HA 1 had an initial training in the emergency preparedness P&P. b. The Emergency Management Plan Evaluation Form dated 2/10/22, showed the hospice conducted a winter storm drill. However, there was no documented evidence of a staff sign-in sheet for the drill. c. The P&P titled Emergency Management Plan had a revised date 5/22. However, there was no documented evidence of a staff sign-in sheet for the training of the revised P&P. On 11/30/23 at 1030 hours, an interview and concurrent record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and document review, the hospice failed to document the investigation of seven of seven complaints and grievances received from 2021 to 2023. This failure created the risk of violating the patient's rights and not providing quality of care and services to the patients receiving care and services at the hospice. --- Findings: Review of the hospices complaints and grievances for the years of 2021 to 2023 was initiated on 11/21/23. The following was identified: - On 2/10/21, a complaint was made related to the HAs punctuality.- On 10/20/21, a grievance was made related to the RNs punctuality and communication regarding schedule changes.- On 11/21/21, a grievance was made related to the RNs failure to refill the patients medication.- On 1/6/22, a complaint was made related to the delay in delivery of requested supplies.- On 6/13/22, a complaint was made related to a broken medication bottle.- On 10/6/22, a complaint was made related to a broken bed for a patient.- On 2/10/23, a complaint was made related to the delay in delivery of supplies. Documentation showed each of the complaints/grievances received was investigated. Each complaint/grievance form showed documentation of the summary of the complaint and grievance; investigation and resolution steps made; resolution outcomes; and follow-up information. However, there was no documented evidence showing the actual investigation of each of the complaints/grievances. For example, on 2/10/21, a complaint was made related to the HAs punctuality. Documentation showed the investigation and resolution steps included reviewing of the care schedules, communication records, and gathering information from involved parties. A conversation was also held with the HA to gather her perspective on the reported incident. However, there was no documented evidence showing the interview and statements from the involved parties conducted. On 11/29/23 at 1415 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. When asked to provide the hospice's complaint and grievance P&Ps, the Administrator/DPCS verified she could not find the P&Ps. On 11/30/23 at 1100 hours, an interview and concurrent document review was conducted with the Director of HR. The Director of HR was informed and acknowledged the findings.

This CONDITION is not met as evidenced by: Based on interview and record review, the hospice failed to ensure the initial and comprehensive assessments were reviewed, completed, and revised to address and meet the patients' care needs as evidenced by: --- Findings: 1. The hospice failed to ensure the comprehensive assessments were completed no later than five calendar days. Cross reference to L523. 2. The hospice failed to ensure the comprehensive assessments had identified the psychosocial and spiritual needs. Cross reference to L524. 3. The hospice failed to ensure the comprehensive assessments had identified the imminence of death. Cross reference to L528. 4. The hospice failed to include all current medications' side effects; actual or potential drug interactions and duplicate drug therapy in the comprehensive assessments; and ensure the medication profiles were reviewed and updated to reflect the current medications. Cross reference to L530. 5. The hospice failed to ensure the initial bereavement assessment was completed. Cross reference to L531. 6. The hospice failed to ensure the updated comprehensive assessments were completed and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses. Cross reference to L533. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the initial and comprehensive assessments to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the initial comprehensive assessments were completed no later than five calendar days for five of 11 sampled patients (Patients 1, 3, 8, 10, and 11). This failure created the risk of not identifying the care needs of these patients. --- Findings: 1. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. The Election of Hospice Benefit Informed Consent dated 5/12/21, showed the family member authorized for hospice services. The initial comprehensive nursing assessment was conducted on 5/12/21. The initial comprehensive psychosocial assessment dated 5/14/21, showed no documented evidence the hospice had completed the initial comprehensive psychosocial assessment for the patient within five days from the election of hospice services. The initial comprehensive spiritual assessment was conducted on 5/28/23, which was more than five calendar days from the election of hospice services. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 2. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. The Election of Hospice Benefit Informed Consent dated 6/6/22, showed the family member authorized for hospice services. Review of the initial comprehensive nursing assessment dated 6/16/22. However, further review of the clinical record showed no documented evidence the hospice had completed the comprehensive spiritual and psychosocial assessment for the patient within five days from the election of hospice services. In addition, the initial comprehensive nursing assessment was completed more than five days from the election of hospice services. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 3. Review of Patient 8's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 8/25/22. The patient was certified for hospice service during the certification period from 8/25/22 to 11/22/22. The Election of Hospice Benefit Informed Consent dated 8/25/22, showed the family member authorize for hospice services. The initial comprehensive nursing assessment dated 8/25/22, showed the patient had multiple skin tears and bruising due to thin fragile skin. There was no documented evidence on the location and measurement of the patients skin tears. The initial spiritual assessment dated 9/7/22, showed the Chaplain was on vacation when the patient was admitted. However, the above assessments were not completed within five days from the election of hospice services. On 11/30/23 at 1130 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 4. Review of Patient 10s closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 4/14/22. The patient was certified for hospice service during the certification period from 10/4/22 to 12/2/22. The Election of Hospice Benefit Informed Consent dated 4/14/22, showed the family member authorized for hospice services. The initial comprehensive nursing assessment was conducted on 4/14/22. The Communication Note dated 4/18/22, showed the Chaplain made an initial telephone call to the PCG/family member and had a brief conversation. Documentation showed the chaplain service was declined. Further review of the clinical record showed no documented evidence an initial psychosocial and spiritual assessment was completed within five days from the election of hospice services. On 11/30/23 at 1120 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 5. Review of Patient 11s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 4/23/21. The patient was certified for hospice services during the certification period from 10/15/22 to 12/13/22. Review of the clinical record showed the hospice had completed the initial comprehensive nursing and spiritual assessments. However, there was no documented evidence showing the hospice had completed the initial comprehensive psychosocial assessment for the patient. On 11/30/23 at 1049 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments had identified the physical, psychosocial, and spiritual needs for five of 11 sampled patients (Patients 1, 3, 8, 10, and 11). This failure created the risk of not identifying the care needs for these patients. --- Findings: 1. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. The initial comprehensive psychosocial assessment dated 5/14/21, showed no documented evidence the hospice had completed the initial comprehensive psychosocial assessment for this patient. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 2. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. Review of the initial comprehensive nursing assessment dated 6/16/22 was conducted. However, further review of the clinical record showed no documented evidence the hospice had completed the comprehensive spiritual and psychosocial assessment for the patient. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 3. Review of Patient 8's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 8/25/22. The patient was certified for hospice service during the certification period from 8/25/22 to 11/22/22. The initial comprehensive nursing assessment dated 8/25/22, showed the patient had multiple skin tears and bruising due to thin fragile skin. The initial nursing comprehensive assessment was incomplete as there was no documented evidence on the location and measurement of the patients skin tears. On 11/30/23 at 1130 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 4. Review of Patient 10s closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 4/14/22. The patient was certified for hospice service during the certification period from 10/4/22 to 12/2/22. The initial comprehensive nursing assessment dated 4/14/22 was conducted. However, there was no documented evidence the volunteer need was assessed. The Communication Note dated 4/18/22, showed the Chaplain made an initial telephone call to the PCG/family member and had a brief conversation. Documentation showed the chaplain service was declined. Further review of the clinical record showed no documented evidence an initial comprehensive spiritual assessment was completed. On 11/30/23 at 1120 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 5. Review of Patient 11s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 4/23/21. The patient was certified for hospice services during the certification period from 10/15/22 to 12/13/22. However, there was no documented evidence showing the hospice had completed the initial comprehensive psychosocial assessment for the patient. On 11/30/23 at 1049 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments had identified the imminence of death for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). This failure created the risk of not appropriately addressing the patients' needs. --- Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 showed no documented evidence the patients' imminence of death were assessed during the initial comprehensive assessment for these patients. For example: 1. Review of Patient 2's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 6/15/19. The patient was certified for hospice services during the certification period from 1/25/23 to 3/25/23. Review of the initial comprehensive nursing and psychosocial assessments dated 6/15/19, showed no documented evidence the patients imminence of death was identified. On 11/30/23 at 0950 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 4's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification periods from 10/30/22 to 12/28/22 and 12/29/22 to 2/26/23. Review of the initial comprehensive nursing and psychosocial assessments dated 8/13/21 and 8/18/21, respectively, showed no documented evidence the patients imminence of death was identified. On 11/30/23 at 1005 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. Review of the initial comprehensive nursing, psychosocial, and spiritual assessment dated 5/12, 5/14, and 5/28/21, showed no documented evidence the patients imminence of death was identified. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 4. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. Review of the initial comprehensive nursing assessment dated 6/16/22 was conducted. Further review of the clinical record showed no documented evidence the patients imminence of death was identified. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.

Based on observation, interview, and record review, the hospice failed to include all the current medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments; and failed to ensure the medication profiles were reviewed and updated to reflect the current medications for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. --- Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 showed no documented evidence showing the identified medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments. For example: 1. Review of Patient 2's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 6/15/19. The patient was certified for hospice services during the certification period from 1/25/23 to 3/25/23. The IDG Meeting Note dated 1/31/23, showed the following active medication orders:- lorazepam (antianxiety) 0.5 mg PO Q four hours PRN for anxiety; and- morphine sulfate (opioid analgesic) 0.25 ml PO Q two hours PRN for pain and shortness of breath. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan showed concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the IDG Meeting Note dated 1/31/23, showed all medications had been reviewed for effectiveness of the drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence showing the potential drug interactions were identified. On 11/30/23 at 0950 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 4's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification period from 12/29/22 to 2/26/23. The IDG Meeting Note dated 12/29/22 showed the following active medication orders:- lorazepam 1 mg PO Q four hours PRN for anxiety;- morphine sulfate 5 mg PO Q two hours PRN for mild pain and respiratory distress; and- morphine sulfate 20 mg PO Q two hours PRN for severe pain and severe respiratory distress. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan showed concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.Further review of the IDG Meeting Note dated 12/29/22 showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence showing the potential drug interactions were identified. On 11/30/23 at 1005 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. a. The IDG Meeting Note dated 9/12/23, showed the patients active medications included Seroquel (antipsychotic) 50 mg one tablet Q HS and morphine sulfate (opioid analgesic) 0.5 mg SL Q four hours PRN for pain. According to Lexi-Comp's pharmacology website, the use of morphine sulfate and Seroquel included the interactions for risk of profound sedation, respiratory depression, hypotension, coma, or death. Further review of the patients current medication list showed the medication profile have been reviewed for drug therapy related to laboratory monitoring, effectiveness of drug therapy, actual or potential drug/food interactions, drug to drug interactions, drug side effects, and duplicate drug therapy. However, there was no documented evidence the potential drug interactions were identified. b. The Patient Medication Profile dated 11/14/23, showed the patients medications included lorazepam (antianxiety) 0.5 mg tablet PO Q four hours PRN for anxiety; Ativan (brand name for lorazepam) 2 mg/ml 0.5 ml Q four hours PRN for agitation/anxiety/SOB/seizures; and Seroquel 25 mg PO once a day in the morning and 50 mg one tablet PO Q HS. A joint home visit with the Administrator/DPCS to the patient's home was conducted on 11/15/23 at 1000 hours. Review of the patient's medications with the Administrator/DPCS and Family Member 1 was conducted. Family Member 1 stated the patient only had the liquid form of Ativan and the Seroquel 25 mg in the morning was not being used. On 11/15/23 at 1315 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated the patient never had lorazepam tablet and Seroquel 25 mg once in the morning was not being administered to the patient. * The hospice failed to update patients medication profile. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 4. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. The IDG Meeting Note dated 10/20/22, showed the patients active medications included lorazepam 1 mg Q HS for agitation/anxiety and morphine sulfate 20 mg/ml 0.5 mg Q two hours PRN for pain/SOB. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the patients current medication list showed the medication profile have been reviewed for drug therapy related to laboratory monitoring, effectiveness of drug therapy, actual or potential drug/food interactions, drug to drug interactions, drug side effects, and duplicate drug therapy. However, there was no documented evidence the potential drug interactions were identified. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the initial bereavement assessment was completed for seven of 11 sampled patients (Patients 1, 3, 5, 6, 7, 9, and 11). This failure created the risk of not providing an appropriate, consistent, and quality care to these patients. --- Findings: Review of the hospices P&P titled Bereavement Services dated May 2022 showed a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed. 1. Review of Patient 5's closed clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/23/22. The patient was certified for hospice services during the certification period from 12/23/22 to 3/22/23. Review of the clinical record showed the initial bereavement assessment was completed on 1/3/22. However, further review of the clinical record showed no documented evidence the bereavement assessment was incorporated in the patients POC. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 12/1/22 to 1/29/23. Review of the clinical record showed the initial bereavement assessment was completed on 2/8/22. However, further review of the clinical record showed no documented evidence the bereavement assessment was incorporated in the patients POC. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 9s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 5/11/23. The patient was certified for hospice services during the certification periods from 11/7/22 to 1/5/23 and 1/6/23 to 3/6/23. Further review of the clinical record showed no documented evidence the initial bereavement assessment was completed. On 11/30/23 at 1034 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 11s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 4/23/21. The patient was certified for hospice services during the certification period from 10/15/22 to 12/13/22. Further review of the clinical record showed no documented evidence the initial bereavement assessment was completed. On 11/30/23 at 1049 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 5. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. Review of the clinical record showed no documented evidence the initial bereavement assessment was completed. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 6. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. Review of the clinical record showed no documented evidence the initial bereavement assessment was completed. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 7. Review of Patient 6's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 1/4/23. The patient was certified for hospice service during the certification period from 1/4/23 to 4/3/23. Review of the clinical record showed no documented evidence the initial bereavement assessment was completed. On 11/30/23 at 1050 hours, a concurrent interview and clinical record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments were completed and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). These failures created the risk of not addressing the care needs for these patients. --- Findings: 1. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 showed no documented evidence the need for volunteer was assessed during the ongoing assessment with the IDG. For example: a. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. Review of the clinical record showed the IDG met on 9/12, 9/26, 10/10, and 10/24/23. However, there was no documented evidence the need for a volunteer was assessed during the meetings. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. b. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. Review of the clinical record showed the IDG met on 10/20 and 11/3/22. However, there was no documented evidence the need for a volunteer was assessed during the meetings. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. c. Review of Patient 2's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 6/15/19. The patient was certified for hospice services during the certification period from 1/25/23 to 3/25/23. Review of the clinical record showed the IDG met every 14 days. However, there was no documented evidence showing the volunteer needs were assessed during the meetings. On 11/30/23 at 0950 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. d. Review of Patient 4's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification periods from 10/30/22 to 12/28/22 and 12/29/22 to 2/26/23. Review of the clinical record showed the IDG met every 14 days. However, there was no documented evidence showing the volunteer needs were assessed during the meetings. On 11/30/23 at 1005 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. Review of the clinical record showed the IDG met on 10/20 and 11/3/22. However, there was no documented evidence the patients psychosocial need was assessed during the meetings. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.

This CONDITION is not met as evidenced by: Based on interview and record review, the hospice failed to ensure the IDG, care planning, and coordination of services were provided to meet the patients' care needs as evidenced by: --- Findings: 1. The hospice failed to ensure the care and services were provided in accordance with the POCs. Cross reference to L543. 2. The hospice failed to develop an individualized written POCs that reflected goals and interventions based on the problems identified. Cross reference to L545. 3. The hospice failed to ensure the POCs included measurable outcomes. Cross reference to L548. 4. The hospice failed to ensure the IDG had reviewed/revised the POCs no less frequently than every 15 calendar days. Cross reference to L552. 5. The hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs. Cross reference to L553. 6. The hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided. Cross reference to L554. 7. The hospice IDG failed to ensure the care and services were provided in accordance with the POCs. Cross reference to L555. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for four of 11 sampled patients (Patients 2, 4, 7, and 11). This failure created the risk of not providing an appropriate, consistent, and quality care to these patients. --- Findings: 1. Review of Patient 2's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 6/15/19. The patient was certified for hospice services during the certification period from 1/25/23 to 3/25/23. The IDG Meeting Note dated 1/31/23, cited SN visits once a week. However, review of the clinical record showed no documented evidence the SN visited the patients home during Week 4 (2/12/23 to 2/18/23). On 11/30/23 at 0950 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 4's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification period from 10/30/22 to 12/28/22. The IDG Meeting Note dated 11/3/22, cited SN visits two to three times a week plus two PRN visits for pain and symptom management. However, review of the clinical record showed no documented evidence the SN visited the patients home during Week 3 (11/13/22 to 11/19/22). On 11/30/23 at 1005 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 10/2/22 to 11/30/23. The IDG Meeting Note dated 10/6/22, cited MSW visits one to three times per month plus two PRN visits for psychosocial support. However, review of the clinical record showed no documented evidence the MSW visited the patients home throughout the certification period as cited in the POC. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 11s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 4/23/21. The patient was certified for hospice services during the certification period from 10/15/22 to 12/13/22. The IDG Meeting Note dated 10/20/22, cited MSW visit once per month plus one PRN visits to provide support to the patient and family. However, review of the clinical record showed no documented evidence the MSW visited the patients home throughout the certification period as cited in the POC. On 11/30/23 at 1049 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the written POCs were developed to reflect the patient/family goals and interventions based on the problems identified for eight of 11 sampled patients (Patients 1, 2, 3, 6, 7, 8, 9, and 10), creating the risk of not addressing the care needs for these patients. --- Findings: 1. Review of Patient 2's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 6/15/19. The patient was certified for hospice services during the certification period from 1/25/23 to 3/25/23. The RN Visit Notes dated 1/27, 2/4, 2/7, and 2/21/23, showed the patient continued to have altered sleep pattern. However, review of the updated IDG Meeting Notes and POCs during the certification period showed no documented evidence an individualized POC was developed to address the patients altered sleep pattern. On 11/30/23 at 0950 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 2. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 12/1/22 to 1/29/23. The IDG Meeting Notes during the certification period showed the care plan problems related to altered circulatory and respiratory status were identified. However, there was no documented evidence showing the goals and interventions developed for the patient to address these issues. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 9s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 5/11/23. The patient was certified for hospice services during the certification periods from 11/7/22 to 1/5/23 and 1/6/23 to 3/6/23. The IDG Meeting Notes during the certification period showed the care plan problems related to altered circulatory, respiratory, and nutrition status were identified. However, there was no documented evidence showing the goals and interventions developed for the patient to address these issues. On 11/30/23 at 1034 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 4. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. The IDG Meeting Notes dated 9/12, 9/26, 10/10, and 10/24/23, showed the patient's identified problems included altered respiratory status and altered GI nutrition. However, there was no documented evidence of the patient and family goals and interventions based on the problems identified. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 5. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. The IDG Meeting Note dated 10/20/23, showed the patients insomnia was managed with temazepam (sedative) 60 mg at bedtime. However, there was no documented evidence of a POC developed to address patients insomnia and the use of temazepam. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 6. Review of Patient 6's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 1/4/23. The patient was certified for hospice service during the certification period from 1/4/23 to 4/3/23. The IDG Meeting Notes dated 1/17, 1/31, 2/14, and 2/28/23, showed the patient's identified problem included altered neuro status. However, there was no documented evidence of patient and family goals and interventions based on the problems identified. On 11/30/23 at 1050 hours, a concurrent interview and clinical record review was conducted with the Director of HR. He was informed and acknowledged the findings. 7. Review of Patient 8's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 8/25/22. The patient was certified for hospice service during the certification period from 8/25/22 to 11/22/22. The initial nursing comprehensive assessment dated 8/25/22, showed the patient had been on Ciprofloxacin (antibiotic) 250 mg BID for UTI. However, there was no documented evidence of a POC developed to address the UTI and the use of antibiotic. On 11/30/23 at 1130 hours, a concurrent interview and clinical record review was conducted with Administrator/DPCS. She was informed and acknowledged the findings. 8. Review of Patient 10s closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 4/14/22. The patient was certified for hospice service during the certification period from 10/4/22 to 12/2/22. The IDG Meeting Note dated 10/6/22, showed the patients medication included melatonin (supplement) 5 mg daily at bedtime for sleep. However, there was no documented evidence of a POC developed to address the patients use of melatonin for sleep. On 11/30/23 at 1120 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). This failure created the risk of not evaluating the POC and providing an appropriate care and services to these patients. --- Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 showed no documented evidence the POCs included measurable outcomes. For example: 1. Review of Patient 5's closed clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/23/22. The patient was certified for hospice services during the certification period from 12/23/22 to 3/22/23. The IDG Meeting Note dated 12/29/22, showed a care plan problem was developed for spiritual services. The goals included for the patient/PCG/family to receive an optimal support related to religious and spiritual distress which was not measurable. There was no documentation to specify what was the optimal support the patient needed to receive. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 12/1/22 to 1/29/23. The IDG Meeting Note dated 12/29/22, showed a care plan problem was developed for alteration in nutritional status related to low nutritional intake. The goals included for the patient to have adequate food and fluids to maintain comfort which was not measurable. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. The IDG Meeting Note dated 9/12, 9/26, 10/10, and 10/24/23, showed the patient's identified problems with the established goal and interventions. However, the POC failed to include measurable outcome for the patient's identified problem. For example, the goal for potential for increasing spiritual needs related to ongoing patient decline was for the patient/PCG to receive optimal support regarding religious/spiritual needs. There was no measurable outcome as to what optimal support regarding religious/spiritual needs for the patient was. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 4. Review of Patient 6's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 1/4/23. The patient was certified for hospice service during the certification period from 1/4/23 to 4/3/23. The IDG Meeting Notes dated1/17, 1/31, 2/14, and 2/28/23, showed the patient's identified problems with the established goal and interventions. However, the POC failed to include measurable outcome for the patient's identified problem. For example, the goal for potential for alteration in circulatory status was for the patient to maintain optimum peripheral circulation for the duration for the plan of care. There was no measurable outcome as to what optimal peripheral circulation for the patient was. On 11/30/23 at 1050 hours, a concurrent interview and clinical record review was conducted with the Director of HR. He was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient's POCs no less frequently than every 15 calendar days for seven of 11 sampled patients (Patients 1, 3, 5, 8, 9, 10, and 11), creating the risk of not providing an appropriate, consistent, and quality care to these patients. --- Findings: The hospices P&P titled Interdisciplinary Group Membership and Responsibilities dated 5/22 showed the hospice interdisciplinary team/group members will include at a minimum: physician, RN, social worker, and pastoral or other counselor. Additional members may include PT, OT, ST, RD, Pharmacist, Home Care Aide/Homemaker, and Volunteer. 1. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. The Skin Assessment dated 9/21/23, showed the patient had a Stage 3 sacral pressure injury. The IDG Meeting Note dated 9/26/23, showed on the assessment section of the note the patient had a Stage 1 buttock pressure injury and a Stage 3 sacral pressure injury. The section of the note which included the Plan of Care showed a care plan problem addressing altered skin integrity related to terminal illness, decreased mobility, and nutritional intake. However, there was no documented evidence the care plan problem was updated to address the patients Stage 3 sacral pressure injury. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 2. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. The SN note dated 10/31/23, showed the patient reportedly had slid off the bed half way at the open end of the head of bed where the bedrail did not extend. Documentation showed the patient sustained a small superficial abrasion along the nose when she slid off the bed half way. The IDG Meeting Note dated 11/3/23, showed a care plan problem for fall risk (potential for harm). However, there was no documented evidence the care plan problem was updated to address the patient had slid off the bed and sustained superficial abrasion along the nose. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 3. Review of Patient 8's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 8/25/22. The patient was certified for hospice service during the certification period from 8/25/22 to 11/22/22. a. The IDG Meeting Note dated 11/3/22, showed on the assessment section of the note the patient had the Stage 4 buttock pressure injury and Stage 3 back pressure injury. The section of the note which included the Plan of Care showed a care plan problem addressing Stage 3 pressure injury and altered skin integrity related to decreased mobility and impaired nutritional intake. However, there was no documented evidence the care plan problem was updated to address the current stage and location of the pressure injuries. b. The HA Assignment dated 9/13/23, showed HA services was declined. The IDG Meeting Note dated 9/22, 10/6, 10/20, 11/3, and 1/17/22, showed HA visits 2 W (two visits a week). However, the POC related to the frequency of HA visits was not updated. On 11/30/23 at 1130 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 4. Review of Patient 10s closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 4/14/22. The patient was certified for hospice service during the certification period from 10/4/22 to 12/2/22. a. The IDG Meeting Note dated 10/6/22, showed no documented evidence all IDG members had reviewed/revised the patient's POCs at least every 15 days as there were no signatures of the RN, MSW, and Spiritual Counselor in the meeting note. b. The SN note dated 11/16/22, showed the patient with residual cough due to upper respiratory infection. Documentation showed Robitussin (cough medication) was administered for cough. The IDG Meeting Note dated 11/17/22, showed a care plan problem for alteration in respiratory status related to shortness of breath. * However, there was no documented evidence the care plan problem was updated to address the patients cough. On 11/30/23 at 1120 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 5.a. Review of Patient 5's closed clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/23/22. The patient was certified for hospice services during the certification period from 12/23/22 to 3/22/23. Review of the IDG Meeting Notes during the certification period showed the IDG met every 14 days. However, there were multiple dates when not all IDG members participated in the meetings as evidenced by the lack of notes and signatures on the attendance section. For example, on 1/17/23, there was no documented evidence showing the MSW and Chaplains notes and signatures during the meeting. b. Further review of the clinical record showed the HA visit notes on 12/30/22, 1/6, 1/11, 1/12, 1/16, 1/18, 1/23, 1/25, 1/30, 2/1, 2/6, 2/8, 2/13, 2/15, and 2/20/23. The HA documented the patient declined HA services for each visit note. However, the IDG Meeting Notes during the certification period had no documented evidence showing the IDG had updated the comprehensive assessments and discussed whether the patient still needed HA services. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 6.a. Review of Patient 9s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 5/11/23. The patient was certified for hospice services during the certification periods from 11/7/22 to 1/5/23 and 1/6/23 to 3/6/23. The RN Visit Note dated 1/11/23, showed the patient was experiencing increased dysphagia (difficulty swallowing) and was on aspiration precautions. The note also showed the patient had a Stage 2 pressure injury on the right ankle. Review of the IDG Meeting Note dated 1/17/23, showed a care plan problem for altered nutrition was developed. However, there was no documented evidence showing the care plan problem was updated to include the patients increased dysphagia and risk for aspiration. b. The IDG Meeting Note dated 1/3/23, cited Chaplain visits one to three times per month. Review of the clinical record showed no documented evidence the Chaplain visited the patients home as cited in the POC. However, review of the IDG Meeting Notes during the certification period showed no documented evidence the IDG had updated the comprehensive assessments and discussed the Chaplains missed visits. On 11/30/23 at 1034 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 7. Review of Patient 11s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 4/23/21. The patient was certified for hospice services during the certification period from 10/15/22 to 12/13/22. The RN Visit Note dated 10/17/22, showed the patient had Stage 4 pressure injuries to the coccyx and back torso. The patient also had a Stage 3 pressure injury on the left elbow. Review of the IDG Meeting Note dated 10/20/22, showed a care plan was developed for the patients altered skin integrity. However, there was no documented evidence showing the care plan problem was updated to include each of the patients wounds. On 11/30/23 at 1049 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patients' progress toward goals specified in the POCs for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). This failure created the risk of not identifying the care needs and providing necessary care and services for these patients. --- Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 showed no documented evidence the revised POCs included the patients progress towards goals. For example: 1. Review of Patient 5's closed clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/23/22. The patient was certified for hospice services during the certification period from 12/23/22 to 3/22/23. The revised POCs and IDG Meeting Notes for the certification period showed the hospice identified patient care problems related to altered comfort, respiratory status, and elimination; psycho-social adjustment/coping; and spiritual services. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 12/1/22 to 1/29/23. The revised POCs and IDG Meeting Notes for the certification period showed the hospice identified patient care problems related to knowledge and training; potential for harm; altered comfort, nutrition, elimination, and skin integrity; and spiritual services. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. The IDG Meeting Note dated 9/12/23, showed the hospice identified patient care problems, included potential for harm, altered discomfort, altered neuro status, altered nutrition, altered elimination, altered skin integrity, psycho-social adjustment coping, and potential for increasing spiritual needs. The goals were established for these identified problems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 4. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. The IDG Meeting Note dated 9/12/23, showed the hospice identified patient care problems, included knowledge and training, potential for harm, altered comfort, altered neuro status, altered respiratory status, altered nutrition, altered elimination, and spiritual services. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for seven of 11 sampled patients (Patient 1, 3, 5, 6, 7, 8, and 9). This failure created the risk of not addressing the care needs for these patients. --- Findings: The hospice's P&P titled Interdisciplinary Group Membership and Responsibilities dated 5/22 showed the IDG will: - Participate in the establishment of the POC for each patient admitted to the hospice service. - Participate in the periodic review and updating of the POC for each patient and family receiving hospice services. - Provide and/or supervise and coordinated hospice care and services. - Establish policies and procedures governing day to day provision of hospice care and services - Review and resolve conflict of care and ethical issues - Plan for community education regarding hospice services - Participate in quality assessment performance improvement activities - Review utilization criteria for each discipline 1. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. The IDG Meeting Notes dated 8/29, 9/12, and 9/26/23, showed SN visit 1 W and four PRN for comfort measures. a. The SN notes dated 9/12/23 for Week 3 (9/10/23 to 9/16/23) and 9/25/23 for Week 5 (9/24/23 to 9/30/23) showed SN telehealth visits were conducted. There was no documented evidence the reason telehealth visits were conducted instead of one home visit as week as cited. b. The SN note dated 9/21/21, showed the PCG reported the patient developed a sacral pressure injury. The Skin Assessment form dated 9/21/23, showed the patients Stage 3 sacral pressure injury had a wound measurement of 2.8 cm (length) X 3.1 cm (width). * There was no documented evidence of the wound depth measurement. c. The physicians order dated 9/21/23, showed to cleanse sacral wound with NS, pat dry, apply Medihoney (wound dressing) and apply ";island" dressing. The order showed the SN to provide dressing change once a week; and the PCG and family to provide a dressing change if wet or soiled. The SN note dated 9/25/23, showed a telehealth visit was conducted for Week 5 (9/24/23 to 9/30/23). However, there was no documented evidence the SN performed sacral pressure injury measurement and wound care for Week 5. * The IDG had failed to coordinate, supervise, and direct the care for the patients wound and telehealth visit. On 11/30/23 at 1100 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She stated wound measurement should be performed weekly. She was informed and acknowledged the findings. 2. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. The IDG Meeting Note dated 10/20 and 11/3/22, showed HA visits 2W. The HA note showed the HA conducted a visit on 11/2/23 for Week 4 (10/30 to 11/5/23). The Communication Note dated 11/4/22, showed the HA called the office to report closure on the freeway on the way to the patients home. Documentation showed the hospice called the B&C facility about the delay and asked to cancel the visit. However, there was no documented evidence the HA attempted to schedule a visit the following day of the week to ensure HA services were provided. The IDG failed to supervise and coordinate the HA service. On 11/30/23 at 1110 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 3. Review of Patient 6's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 1/4/23. The patient was certified for hospice service during the certification period from 1/4/23 to 4/3/23. The initial comprehensive psychosocial assessment dated 1/6/23, showed the MSW conducted a telehealth ";contact" with the patients spouse. However, there was no documented evidence on the reason telehealth was conducted. The initial comprehensive spiritual assessment dated 1/6/23, showed the Chaplain conduced the initial assessment on the phone with the patients husband. Documentation showed the Chaplain worked from the Monterey office and was assisting the Orange County office. * The IDG failed to supervise the use of telehealth with the MSW and Chaplain. On 11/30/23 at 1050 hours, a concurrent interview and clinical record review was conducted with the Director of HR. He was informed and acknowledged the findings. 4. Review of Patient 8's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 8/25/22. The patient was certified for hospice service during the certification period from 8/25/22 to 11/22/22. a. The initial spiritual assessment dated 9/7/22, showed the Chaplain was on vacation when the patient was admitted. Documentation showed the Chaplain spoke with the PCG/family member on the phone. Documentation showed the Chaplain was unable to observe the patient. There was no documented evidence on the reason telehealth was conducted. b. The IDG Meeting Note dated 9/8, 9/22, 10/6, and 10/20/22, showed SN visits 1-3 W (one to three visits a week) and 2 PRN visits for comfort measures. The Skin Assessment note dated 9/30/22, showed the PCG reported wound to sacral area. Documentation showed the physician was informed and new orders were obtained. Another section of the note showed the patient had a Stage 3 buttocks pressure injury. However, the wound location was not consistent. The physicians order dated 9/30/23, showed from 9/30/22 to 10/7/22, cleanse sacral wound site with wound wash, pat dry with sterile gauze, apply Medihoney (wound dressing) to wound bed, and cover with silicone foam dressing. However, there was no documented evidence on the frequency of the wound treatment. The SN note dated 10/7/22, showed new pressure wound was found on the center mid back. Documentation showed the physician was notified and new orders for a wound evaluation from a wound care company. The physicians order dated 10/7/22, showed the following information: - Cleanse the mid back with wound wash, pat dry with a gauze, apply Medihoney (wound dressing) to wound bed, and cover with a silicone foam dressing. - Cleanse sacral wound with Dermal Wound Cleanser, pat dry with gauze sponge, apply Tetracyte (topical antibiotic), Therahoney (wound dressing), Cuticerin (wound dressing) to the wound bed, followed by Durafiber Ag (wound dressing), and cover with Allevyn foam dressing three times a week. Use abdominal pad followed by Covrsite dressing in between Allevyn Life Foam dressing intervals. Secure dressing with Primafix Plus (retention tape) PRN. * However, there was no documented evidence on the frequency of the wound treatment for the mid back wound. The SN note showed the RN conducted a visit on 10/10/23 for Week 8 (10/9/22 to 10/15/22). Documentation showed wound care to the bottom wound was provided. Documentation showed the wound was cleansed with sodium chloride, pat dry, applied Medihoney, and covered with a foam dressing. * However, there was no documented evidence of the midback wound measurement was conducted for Week 8. In addition, the treatment performed on 10/10/23, to the buttock (sacral) was not consistent with the POC. The SN note showed the RN conducted a visit on 10/17/23 for Week 9 (10/16/22 to 10/22/22). * However, there was no documented evidence the midback wound measurement was conducted for Week 9. * In addition, the IDG Meeting Note dated 10/20/23, showed no documented evidence the IDG had updated the patients comprehensive assessment related to the midback wound measurement. The SN note dated 11/22/22, showed the patient had no BM for three days, and bisacodyl (laxative) suppository was administered per family request; educated on patient ";declined and significant reduced intake and effect with wound noted to the sacral area." Documentation showed site appears to have necrotic and slough tissue, possibly ";stage 3." Documentation showed the new orders obtained from the physician. * However, there was no documented evidence of what were the new orders obtained from the physician. * The IDG failed to supervise and direct the care of the patient related to wound care and telehealth visits. On 11/30/23 at 1130 hours, a concurrent interview and clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 5. Review of Patient 5's closed clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/23/22. The patient was certified for hospice services during the certification period from 12/23/22 to 3/22/23. Further review of the clinical record showed the initial psychosocial assessment was completed on 1/3/23 per the PCGs request. The initial spiritual assessment was completed on 12/27/22. However, both assessments were made via telehealth. The IDG failed to supervise, coordinate, and ensure the MSW and Chaplain conducted the initial assessments at the patients home. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 6. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 12/1/22 to 1/29/23. Further review of the clinical record showed the initial psychosocial assessment was completed on 2/8/22. However, the assessment was made via telehealth. The IDG failed to supervise, coordinate, and ensure the MSW conducted the initial psychosocial assessment at the patients home. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 7. Review of Patient 9s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 5/11/23. The patient was certified for hospice services during the certification periods from 11/7/22 to 1/5/23 and 1/6/23 to 3/6/23. Further review of the clinical record showed the initial spiritual assessment was completed on 5/17/22. However, the assessment was made via telehealth. The IDG failed to supervise, coordinate, and ensure the Chaplain conducted the initial spiritual assessment at the patients home. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for four of 11 sampled patients (Patients 2, 4, 7, and 11). This failure created the risk of not providing an appropriate, consistent, and quality care to these patients. --- Findings: 1. Review of Patient 2's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 6/15/19. The patient was certified for hospice services during the certification period from 1/25/23 to 3/25/23. The IDG Meeting Note dated 1/31/23, cited SN visits once a week. However, review of the clinical record showed no documented evidence the SN visited the patients home during Week 4 (2/12/23 to 2/18/23). On 11/30/23 at 0950 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 4's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification period from 10/30/22 to 12/28/22. The IDG Meeting Note dated 11/3/22, cited SN visits two to three times a week plus two PRN visits for pain and symptom management. However, review of the clinical record showed no documented evidence the SN visited the patients home during Week 3 (11/13/22 to 11/19/22). On 11/30/23 at 1005 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 10/2/22 to 11/30/23. The IDG Meeting Note dated 10/6/22, cited MSW visits one to three times per month plus two PRN visits for psychosocial support. However, review of the clinical record showed no documented evidence the MSW visited the patients home throughout the certification period as cited in the POC. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 11s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 4/23/21. The patient was certified for hospice services during the certification period from 10/15/22 to 12/13/22. The IDG Meeting Note dated 10/20/22, cited MSW visit once per month plus one PRN visits to provide support to the patient and family. However, review of the clinical record showed no documented evidence the MSW visited the patients home throughout the certification period as cited in the POC. On 11/30/23 at 1049 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

This CONDITION is not met as evidenced by: Based on interview and record review, the hospice failed to develop an effective, on-going, hospice-wide date-driven QAPI program as evidenced by: --- Findings 1. The hospice failed to measure, analyze, and track quality indicators including adverse events and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations. Cross reference to L562. 2. The hospice failed to use quality indicator data including adverse events, infection control, or other patient care in its design of the QAPI program. Cross reference to L563. 3. The hospice failed to ensure the QAPI had tracked the adverse patient events from the years of 2019 to 2022. Cross reference to L569. 4. The hospice failed to document the reasons for conducting the PIPs and measurable progress achieved on these projects. Cross reference to L573. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the QAPI to ensure quality of care provided to the patients.

Based on interview and record review, the hospice failed to measure, analyze, and track quality indicators including the adverse events and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations for their QAPI program for the years of 2020, 2021, 2022, and 2023. This created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. --- Findings: 1. Review of the QAPI documents failed to show documented evidence of an ongoing quality assessment and performance improvement for the year of 2020. There was no documented evidence of measuring, analyzing, and tracking of quality indicators including adverse events, infection control, and other services provided which would enable the hospice to assess processes of care, hospice services, and operation for the year of 2020. 2. Review of the QAPI documents for the year of 2021, under QAPI Annual Program Review dated 12/30/21, showed the hospice measured, analyzed and tracked quality indicator including adverse events and infection control. However, there was no documented evidence of the data collection, analysis and tracking of adverse events and infection control. For example: The 1st Quarter 2021 QAPI showed no data collection, analysis and tracking of adverse events and infection control. In addition, there was no documented evidence of who had participated in the quarterly QAPI meeting as there was no sign in sheet. On 11/30/23 at 0935 hours, a concurrent interview and record review was conducted with the Administrator/DPCS and RN 1. The Administrator/DPCS was asked for the 2020 QAPI and infection control documents. She was not able to provide. The Administrator/DPCS and RN 1 were informed of the findings. 3.a. Review of the hospice's QAPI program and meeting minutes for 2022 and 2023 was conducted on 11/29/23. Review of the hospices QAPI program for 2023 was initiated on 11/29/23. The QAPI meeting minutes for the first quarter dated 3/21/23, showed the discussion topics included the hospices P&P POC review, compliance for hospice documentation, and review of the first quarter. The meeting was attended by the Administrator, RN, MD, HA, Chaplain, MSW, and LVN. However, there was no documented evidence of the data collection and analysis including tracking of adverse events and infection control information. b. Review of the QAPI program for the second quarter showed documentation revealing fall prevention as the PIP. The documentation included the P&P for the fall prevention program and educational materials for the patient and family to prevent falls. The Fall Occurrence Audit document was also included; however, it was blank. There was no documented evidence showing the data collected for the quarter, including adverse events and infection control information. In addition, there was no documented evidence of the meeting minutes and who had attended the meeting. c. Review of the QAPI program for the third quarter showed documentation revealing pressure ulcers as the PIP. The documentation included information on assessment and monitoring; staff training and education; protocols and guidelines; equipment and resources; communication and collaboration; performance monitoring and reporting; continuous quality improvement; and feedback and adaptation. There was no documented evidence showing the data collected for the quarter, including tracking of adverse events and infection control information. In addition, there was no documented evidence of the meeting minutes and who had attended the meeting. 4.a. Review of the hospices QAPI program for 2022 was initiated on 11/29/23. The QAPI meeting agenda for the first quarter dated 4/7/22, showed the discussion topics included perception of care reports, PIPs, performance measures, quality indicator audits, action plans, adverse events, incident reports/concerns/grievances, and infection control. Documentation included individual patient chart audits, number of after-hour calls, and infection control data. However, the agenda did not show the content of the discussion. There was no documented evidence of the analysis of the data collected, including tracking of adverse events. b. The QAPI meeting agenda for the second quarter dated 6/30/22, showed the discussion topics included perception of care reports, PIPs, performance measures, quality indicator audits, action plans, adverse events, incident reports/concerns/grievances, and infection control. Documentation included individual patient chart audits, educational material related to pain management, and an infection control observation form for one employee. However, the agenda did not show the content of the discussion. There was no documented evidence of the analysis of the data collected, including tracking of adverse events and infection control. c. The QAPI meeting agenda for the third quarter, dated 10/6/22, showed the discussion topics included perception of care reports, PIPs, performance measures, quality indicator audits, action plans, adverse events, incident reports/concerns/grievances, and infection control. Documentation included individual patient chart audits, infection control date, and educational material related to fall prevention. However, the agenda did not show the content of the discussion. There was no documented evidence of the analysis of the data collected, including tracking of adverse events. d. The QAPI meeting agenda for the fourth quarter dated 12/29/22, showed the discussion topics included perception of care reports, PIPs, performance measures, quality indicator audits, action plans, adverse events, incident reports/concerns/grievances, and infection control. Documentation included patient and family satisfaction data; individual patient chat audits; fall occurrence; and infection control data. However, the agenda did not show the content of the discussion. There was no documented evidence of the analysis of the data collected, including tracking of adverse events and infection control. On 11/30/23 at 0930 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to use the quality indicator data including adverse events, infection control, or other patient care in the design the QAPI programs for the years of 2020, 2021, 2022, and 2023. This created the risk of not including relevant data for performance improvement to improve care and services provided to the patients. --- Findings: 1. Review of the hospice's QAPI documents for the years of 2020 and 2021 was conducted on 11/30/23. For the year of 2020, there was no documented evidence the quality indicator data, including adverse events, infection control, or other patient care, being monitored. For the year of 2021, there was no documented evidence the quality indicator data, including adverse events were monitored for each quarter. On 11/30/23 at 0935 hours, a concurrent interview and record review was conducted with the Administrator/DPCS and RN 1. The Administrator/DPCS was asked for the 2020 QAPI and infection control documents. She was not able to provide. The Administrator/DPCS and RN 1 were informed of the findings. 2. Review of the hospice's QAPI program and meeting minutes for 2022 and 2023 was conducted on 11/29/23. However, there was no documented evidence of quality indicator data, including adverse events, infection control, or other patient care, being monitored for each quarter for 2022 and 2023. On 11/30/23 at 0930 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and document review, the hospice failed to ensure the QAPI had tracked the adverse patient events from the years of 2020 to 2023. These failures created the increased risk of not identifying the area for performance improvement. --- Findings: 1. Review of the QAPI documents was conducted on 11/30/23. There was no documented evidence the hospice had tracked the adverse events from the years of 2020 to 2021. On 11/30/23 at 0935 hours, a concurrent interview and record review was conducted with the Administrator/DPCS and RN 1. The Administrator/DPCS was asked for the 2020 QAPI and infection control documents. She was not able to provide. The Administrator/DPCS and RN 1 were informed of the findings. 2. Review of the hospice's QAPI program and meeting minutes for 2022 and 2023 was conducted on 11/29/23. However, there was no documented evidence the hospice had tracked the adverse events from the years of 2022 to 2023. On 11/30/23 at 0930 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and document review, the hospice failed to document the reason for conducting the PIPs and measurable progress achieved on their projects. This failure created the risk of not effectively evaluating the outcomes of the PIPs to improve the care and services provided by the hospice's staff. --- Findings: Review of the hospice's QAPI program and meeting minutes for 2022 and 2023 was conducted on 11/29/23. 1.a. Review of the 2023 QAPI program and meeting minutes showed the following PIPs were conducted for each quarter:-For the first quarter, the PIP was to improve the POCs;-For the second quarter, the PIP was for fall prevention review, documentation, and education; and-For the third quarter, the PIP was for pressure wound reduction and healing. b. Review of the 2022 QAPI Priorities document showed the improvement objective for the year included implementing interdisciplinary approach to improve timely documentation completion to assure continuity of care and provide comprehensive coordinated care to the patients and family. The documentation showed the QAPI committee would oversee and evaluate the data throughout the year. Review of the meeting agenda for each quarter dated 4/7/22, 6/30/22, 10/6/22, and 12/29/22, showed the PIPs, quality indicator audits, and action plans were discussed. However, further review of the QAPI program and meeting minutes for 2022 and 2023 showed no documented evidence of the reasons for conducting these projects and measurable progress achieved on these projects. On 11/30/23 at 0930 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to maintain the coordinated agency-wide program for the surveillance, identification, prevention control, and investigation of infectious and communicable disease, creating the risk of the spread of infections and not improving the infection control program. --- Findings: Review of the agency's P&P titled Evaluating and Maintaining Records of Infections Among Patients dated 5/22 showed: All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery. The Infection Identification-Patient Report Form is completed when any of the following occur: a. A new, actual, or suspected infection is clinically observed by home health personnel. b. Culture is ordered and performed, and the results are positive. c. A new antibiotic is ordered. d. A patient is admitted to a hospital due to an actual or suspected infection. e. A patient dies due to an actual or suspected infection. f. A reportable, communicable infection is identified. g. Patient has temperatures greater than 101 degrees F h. Patient has conjunctivitis. - The Case Manager or the nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection. - Each section of the report should be completed in its entirety. - If patient was admitted to home care from a hospital and a new infection was identified by the clinician within the first 48 hours of service, the source of the suspected infection may be nosocomial. - After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up. - The Performance Improvement Coordinator summarizes, trends, and analyzes the reports. The break down and summary may include, but will not be limited to: a. Number of infection types b. Sources of infection c. Diagnoses d. Age/sex of patients e. Family/caregiver f. Pathogens, if identified g. Follow-up taken h. Orders/medications - The Performance Improvement Coordinator, in conjunction with the Clinical Supervisor, will investigate possible causal factors and recommend appropriate action to contain the transmission of the infection. Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations. - A report on infections will be given at each Performance Improvement Committee meeting. A summary will be forwarded to the IDG. - Information from the summary, analysis, and discussion will be used as part of the organizations risk analysis and annual evaluation of the organizations infection prevention and control activities. 1. Review of the QAPI and infection control documents failed to show documented evidence of coordinated agency-wide program for surveillance, identification, prevention control, and investigation of infectious and communicable disease for 2020. 2. Review of the QAPI and infection control documents for 2021 was conducted on 11/29/23. a. Review of the 1st Quarter 2021 QAPI and infection control documents showed no documented evidence infections cases were collected/monitored. b. Review of the 2nd Quarter 2021 QAPI and infection control documents showed there was one case of UTI and Levaquin (antibiotic) was ordered. However, there was no documented evidence of a patient infection report was completed as per the hospices P&P. c. Review of the 3rd and 4th Quarters 2021 infection control documents showed there were 13 and nine infection cases, respectively. Documentation showed the type of infection, if the infection was acquired while on hospice or if admitted with, the number of repeated infections, and the treatment ordered. However, there was no documented evidence the agency had summarized, analyzed the data, investigated the possible causes of infection, and implemented specific actions to minimize infection. In addition, there was no documented evidence of an patient infection report completed as per the hospices P&P. On 11/30/23 at 0935 hours, a concurrent interview and record review was conducted with the Administrator/DPCS and RN 1. The Administrator/DPCS was asked for the 2020 QAPI and infection control documents. She was not able to provide. The Administrator/DPCS and RN 1 were informed of the findings. 3.a. Review of the QAPI and infection control documents for the years of 2022 and 2023 were conducted on 11/29/23. Review of the QAPI meeting minutes for the first quarter of 2023 dated 3/21/23, showed infection control was one of the topics discussed during the meeting. Documentation showed the expected outcome was 100% compliance with reporting infections and to monitor for trends. However, there was no documented evidence of the infection control data collected. In addition, review of the second and third quarters showed no documented evidence of the infection cases identified. 4. Review of the QAPI meeting minutes and agenda for 2022 showed infection control was discussed each quarter. - For the first quarter, the hospice had identified one case related to skin/soft tissue infection and one case related to UTI. - For the second quarter, the hospice conducted an infection control observation for one employee. - For the third quarter, the hospice identified one case of infection related to conjunctivitis and one case related to skin infection. The hospice also conducted an infection control observation for two employees. - For the fourth quarter, the hospice identified one case of influenza and two cases of UTI. However, there was no documented evidence the infection control data was analyzed and investigated to determine the causes and prevent the prevalence of infection. There was also no documented evidence showing the infection control data was presented and integrated to the QAPI program. On 11/30/23 at 0930 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to implement the bereavement program as per the hospices P&P to address the needs of the bereaved family members for four of four sampled deceased patients (Patients 8, 9, 10, and 11). This failure created the risk of not addressing the bereavement needs of the bereaved family members of these patients. --- Findings: Review of the hospices P&P titled Bereavement Assessment dated May 2022 showed after death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan for intervention, based on the findings of the bereavement follow-up assessment and input from IDG members. The Bereavement Coordinator will document the interventions on the bereavement services checklist. 1. Review of Patient 9s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 5/11/23. The patient was certified for hospice services during the certification periods from 11/7/22 to 1/5/23 and 1/6/23 to 3/6/23. The Visit Note – Discharge Packet dated 1/22/23, showed the patient had expired on 1/22/23. The IDG Meeting Note dated 1/31/23, showed the patients death was discussed and documentation showed the family was coping appropriately. However, further review of the clinical record showed no documented evidence the bereavement follow-up assessment was completed and plan for intervention was developed. On 11/30/23 at 1034 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 2. Review of Patient 11s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 4/23/21. The patient was certified for hospice services during the certification period from 10/15/22 to 12/13/22. The Visit Note – Discharge Packet dated 12/1/22, showed the patient had expired on 12/1/22. The IDG Meeting Note dated 12/15/22, showed the patients death was discussed and documentation showed the family was coping appropriately. However, further review of the clinical record showed no documented evidence the bereavement follow-up assessment was completed and plan for intervention was developed. On 11/30/23 at 1049 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 3. Review of Patient 8's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 8/25/22. The patient was certified for hospice service during the certification period from 8/25/22 to 11/22/22. The Visit Note-Discharge Packet dated 11/27/22, showed the patient was discharged due to death. Review of the clinical record failed to show documented evidence the bereavement assessment was completed after the patients death. The IDG meeting dated 12/1/22, showed no documented evidence the IDG had discussed the family/PCG needs. On 11/30/23 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. 4. Review of Patient 10s closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 4/14/22. The patient was certified for hospice service during the certification period from 10/4/22 to 12/2/22. The Visit Note-Discharged Packet dated 11/18/22, showed the patient was discharged due to death. Review of the clinical record failed to show documented evidence the bereavement assessment was completed after the patients death. On 11/30/23 at 1120 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding.

Based on interview and document review, the hospice failed to ensure Volunteer 1 received orientation and training upon hire. This failure had the potential to negatively impact the hospice's operational performance. --- Findings: Review of the employee file for Volunteer 1 was initiated on 11/21/23. Volunteer 1 was hired on 6/28/18. The employee file showed Volunteer 1 completed the initial orientation and training on 6/28/18. However, there was no documented evidence of the orientation and training when the Volunteer was rehired in 2022. On 11/30/23 at 1053 hours, an interview and concurrent document review was conducted with the Director of HR. The Director of HR was asked to clarify when the Volunteer 1 was hired. The Director of HR verified the Volunteer was initially hired on 6/28/18, left on 12/20/21, and then was hired again on 9/15/22. The Director of HR verified the Volunteer was not provided orientation and training upon rehire in 2022.

Based on interview and document review, the hospice failed to ensure the type of services provided by the volunteer was identified, creating the risk of not thoroughly evaluating the volunteer program. --- Findings: Review of the hospice's volunteer documents for 2021, 2022, and 2023 was conducted on 11/16/23. There was no documented evidence of the type of service the volunteers had provided. For example: Review of the Volunteer Hours showed the following information for Volunteer 2: - On 8/27/21, the time spent by the volunteer was two hour and 15 minutes. - On 9/3/21, the time spent by the volunteer was one hour and 35 minutes. - On 9/10/21, the time spent by the volunteer was two hours and 47 minutes. - On 9/17/21, the time spent by the volunteer was two hours and 30 minutes. - On 9/24/21, the time spent by the volunteer was one hour and 15 minutes. - On 10/1/21, the time spent by the volunteer was two hours and 15 minutes. - On 10/8/21, the time spent by the volunteer was two hours and 45 minutes. - On 10/15/21, the time spent by the volunteer was two hours. - On 10/29/21, the time spent by the volunteer was two hours. - On 11/5/21, the time spent by the volunteer was two hours. - On 11/12/21, the time spent by the volunteer was two hours. - On 12/3/21, the time spent by the volunteer was one hour and 40 minutes. - On 12/17/21, the time spent by the volunteer was one hour and 15 minutes. On 11/30/23 at 1010 hours, an interview and concurrent hospice document review was conducted with the Director of HR. He was informed of the finding.

Based on interview and document review, the hospice failed to ensure the work time spent by the volunteers were consistently summarized, creating the risk of over/underestimating the cost savings the hospice obtained with the use of volunteers. --- Findings: Review of the hospice's volunteer documents for 2021, 2022, and 2023 was conducted on 11/16/23. However, the time spent by the volunteers were not consistent with the volunteer log for cost savings. For example: a. Review of the Visit History showed Volunteer 1 had 0.5 hours for the month of October 2021. Review of the Volunteer Hours form showed Volunteer 2 had nine hours for the month of October 2021. However, review of the 2021 volunteer log for cost savings showed the monthly volunteer hours for October 2021, was 1.4 hours, which was inconsistency with the volunteer hours forms. b. Review of the Visit History showed Volunteer 1 had three hours for the month of December 2022. However, review of the 2022 volunteer log for cost savings showed the monthly volunteer hours for December 2022 was five hours, which was inconsistency with the visit history document. c. Review of the Visit History showed Volunteer 1 had five hours for the month of September 2023. However, review of the 2023 volunteer log for cost savings showed the monthly volunteer hours for September 2023 was 10 hours, which was inconsistency with the visit history document. On 11/30/23 at 1010 hours, an interview and concurrent hospice document review was conducted with the Director of HR. He stated the cost savings were calculated by multiplying the volunteer hours and $21.97. The cost savings documented on the volunteer logs were not accurately calculated as the information for the time spent by the volunteers were inconsistent.

This CONDITION is not met as evidenced by: Based on interview and record review, the hospice failed to ensure the COP addressing Organization and Administration of Services was met. --- Findings: Review of the hospices P&P titled GB dated May 2022 showed the GB will assume full legal authority and responsibility for the operation of the hospice. The GB will serve as the governing authority for the hospice program which will function according to the hospices bylaws. The GB will appoint a qualified Executive Director/Administrator who will be responsible for day-to-day management and operation of the hospice and will establish procedures for systematic executive communication. Performance of the Executive Director/Administrator will be monitored regularly through a procedure established by the GB. 1. The GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with all COPs. Cross reference to L651. 2. The hospice failed to ensure the employees skills competencies were completed annually. Cross reference to L663. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Organization and Administration of Services.

Based on interview and document review, the hospice's GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with the COPs under 418.54 (Initial & Comprehensive Assessment of Patient); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418:58 (Quality Assessment & Performance Improvement); and 418.100 (Organization and Administration of Services). In addition, the hospice's Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all the care provided as follows: - The Administrator failed to ensure the written agreement for one of five contractors (Contractor 1) included the required elements related to bereavement follow-up in the contract as per Title 22. - The Administrator failed to ensure the performance evaluations were completed for two of four employee files reviewed (Chaplain/Bereavement Coordinator and Volunteer 1). - The Administrator failed to ensure the job descriptions were included as part of the employee files for one of four employee files reviewed (Chaplain/Bereavement Coordinator).- The Administrator failed to ensure the physical examination and tuberculosis screening were completed for one of four employee files reviewed (HA 1). These failures had the potential to negatively impact the hospice's operational performance. --- Findings: Review of the hospices P&P titled Governing Body dated May 2022 showed the GB will assume full legal authority and responsibility for the operation of the hospice. The GB will serve as the governing authority for the hospice program which will function according to the hospices bylaws. The GB will appoint a qualified Executive Director/Administrator who will be responsible for day-to-day management and operation of the hospice and will establish procedures for systematic executive communication. Performance of the Executive Director/Administrator will be monitored regularly through a procedure established by the GB. Review of the hospices P&P titled Appointment of Executive Director/Administrator dated May 2022 showed the GB will appoint the Executive Director/Administrator in writing through a procedure established by the GB. The Executive Director/Administrator of hospice will be responsible for the day-to-day operations of the hospice and have the necessary authority to implement his/her responsibilities for the operations, as conferred by the GB. 1. The hospice failed to ensure the COPs under 418.54 (Initial & Comprehensive Assessment of Patient); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418.58 (Quality Assessment & Performance Improvement); and 418.100 (Organization and Administration of Services) were met. Cross references to L520, L536, L559, and L648. 2. According to the Hospice Standards Article 6, Section 6.2 B Contractual Services, when program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. The agreement shall address, but not be limited to the roles and responsibilities of the program and the contracted individual or organization in the bereavement follow-up. Review of the written agreement between the hospice and Contractor 1 providing medical services was initiated on 11/21/23. The written agreement with Contractor 1 did not include the roles and responsibilities of the program and the contracted individual related to bereavement follow-up. On 11/30/23 at 1110 hours, an interview and concurrent document review was conducted with the Director of HR. The Director of HR was informed and acknowledged the finding. 3a. Review of the hospices P&P titled Annual Core Competence dated May 2022 showed hospice personnel, including volunteers will demonstrate proficiency in the performance criteria/skills during the orientation period and at least annually thereafter as part of the annual performance evaluation process. Review of the employee file for the Chaplain/Bereavement Coordinator was initiated on 11/21/23. The Chaplain/Bereavement Coordinator was hired on 10/14/20. The employee file showed the performance evaluations were completed on 11/1/22, 1/11/23, and 10/1/23. However, the performance evaluations did not specify whether the evaluations were conducted for the role of Chaplain or Bereavement Coordinator. In addition, there was no documented evidence the annual performance evaluations were completed for 2021. b. Review of the employee file for Volunteer 1 was initiated on 11/21/23. Volunteer 1 was hired on 6/28/18, left on 12/20/21, and came back again as a volunteer on 9/15/22. However, the employee file showed no documented evidence the annual performance evaluations were completed for 2019, 2020, and 2023. On 11/30/23 at 1053 hours, an interview and concurrent document review was conducted with the Director of HR. The Director of HR was informed and acknowledged the findings. 4. Review of the employee file for the Chaplain/Bereavement Coordinator was initiated on 11/21/23. The Chaplain/Bereavement Coordinator was hired on 10/14/20. The employee file showed a signed job description for the role of Bereavement Coordinator. However, there was no documented evidence a signed job description was completed for the role of Chaplain. On 11/30/23 at 1053 hours, an interview and concurrent document review was conducted with the Director of HR. The Director of HR was informed and acknowledged the finding. 5. Review of the employee file for HA 1 was initiated on 11/21/23. HA 1 was hired on 10/13/23. The employee file showed no documented evidence of HA 1s completed physical examination six months prior to employment or within 14 days of hire. On 11/30/23 at 1053 hours, an interview and concurrent document review was conducted with the Director of HR. The Director of HR was informed and acknowledged the finding.

Based on interview and document review, the hospice failed to ensure the employees skills competencies were completed annually for three of four employee files reviewed (Chaplain/Bereavement Coordinator, Administrator Designee, and Volunteer 1). This failure had the potential to negatively impact the hospice's operational performance. --- Findings: 1.a. Review of the employee file for the Chaplain/Bereavement Coordinator was initiated on 11/21/23. The Chaplain/Bereavement Coordinator was hired on 10/14/20. However, the employee file showed no documented evidence the annual skills competencies were completed for 2022 and 2023. b. Review of the employee file for the Administrator Designee was initiated on 11/21/23. The Administrator Designee was hired on 8/27/19. However, the employee file showed no documented evidence the annual skills competencies were completed from 2020 to 2023. c. Review of the employee file for Volunteer 1 was initiated on 11/21/23. Volunteer 1 was hired on 6/28/18, left the hospice on 12/20/21, and came back again as a volunteer on 9/15/22. However, the employee file showed no documented evidence the annual skills competencies were completed for 2019, 2020, and 2023. On 11/30/23 at 1053 hours, an interview and concurrent document review was conducted with the Director of HR. The Director of HR was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the physician reviewed the patients clinical information to recertify the patient for hospice services for one of 11 sampled patients (Patient 9). This failure created the risk of not identifying the care needs for this patient. --- Findings: Review of Patient 9s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 5/11/23. The patient was certified for hospice services during the certification periods from 11/7/22 to 1/5/23 and ";1/6/23 to 3/6/23." The patient had expired on 1/22/23. The IDG Meeting Note dated 1/17/23, showed the patients benefit period was from 1/6/23 to 3/6/23. Further review of the clinical record showed the patient continued to receive hospice services on 1/9, 1/11, 1/12, 1/16, 1/17, 1/18, 1/19, and 1/22/23. However, there was no documented evidence the certification of terminal illness was completed prior to the patient receiving hospice services on 1/9/23. On 11/30/23 at 1034 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS acknowledged the finding and stated the patient was recertified. However, she was unable to provide documented evidence to show the certification of terminal illness was completed by the physician.

Based on interview and record review, the hospice failed to ensure the patients' clinical records were complete and accurate for three of 11 sampled patients (Patients 1, 2, and 4). This failure created the risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete and inaccurate documentation. --- Findings: 1. Review of Patient 1's clinical record was initiated on 11/14/23. The clinical record showed the SOC was 5/12/21. The patient was certified for hospice service during the certification periods from 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23. The Skin Assessment form dated 10/20/23, showed the patients Stage 3 sacral pressure injury had a measurement of 2.3 cm (length) X 2.1 cm (width). The form also showed the wound had healed and the skin was intact. However, the skin assessment was inaccurate. On 11/30/23 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. 2. Review of Patient 2's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 6/15/19. The patient was certified for hospice services during the certification period from 1/25/23 to 3/25/23. Review of the RN Visit Note dated 2/4/23, showed the patient's last bowel movement was on 1/20/23. Under the Elimination section, the RN documented ";yes" to show the patients symptoms were managed and to continue with the POC. Further review of the clinical record showed no additional documentation related to the patient not having a bowel movement since 1/20/23. On 11/30/23 at 0950 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS acknowledged the finding and stated the RN documented the incorrect date by mistake. 3. Review of Patient 4's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification period from 10/30/22 to 12/28/22. The IDG Meeting Note dated 11/3/22, cited SN visits two to three times per week plus two PRN visits for pain and symptom management. Review of the visit notes showed the RN visited the patient throughout the certification period. However, the RN documented she was conducting LVN supervisory visits when only the RN visited the patients home. For example, the RN Visit Note on 12/8/22, showed the RN had an LVN supervisory visit and the LVN was following the POC and met the patients needs. However, further review of the clinical record showed no documented evidence an LVN had visited the patients home. On 11/30/23 at 1005 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.

Based on interview and record review, the agency failed to ensure the physicians orders were complete for seven of 11 sampled patients (Patient 3, 5, 6, 7, 8, 9, and 10), creating the risk of not providing appropriate, consistent, and quality care to the patient. --- Findings: 1. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice service during the certification period from 10/14/22 to 12/12/22. The Frequency Order (undated) showed starting 8/2/23 to 11/15/23, chaplain services was declined. Documentation showed the Chaplain/Bereavement Coordinator and Physician electronically signed the form on 10/11/22 and 10/18/22, respectively. However, there was no documented evidence when the above physicians order was obtained. On 11/30/23 at 1100 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. 2. Review of Patient 6's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 1/4/23. The patient was certified for hospice service during the certification period from 1/4/23 to 4/3/23. The Frequency Order (undated) showed starting 1/6/23 to 3/2/23, chaplain services 1 to 3 times monthly. Documentation showed the Chaplain/Bereavement Coordinator, and Physician electronically signed the form on 1/6/23 and 1/13/23, respectively. However, there was no documented evidence when the above physicians order was obtained. On 11/30/23 at 1050 hours, an interview and concurrent closed clinical record review was conducted with the Director of HR. He was informed and acknowledged the finding. 3. Review of Patient 8's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 8/25/22. The patient was certified for hospice service during the certification period from 8/25/22 to 11/22/22. The Start Frequency Order (undated) showed starting 9/7/22 to 11/27/22, chaplain services 1 to 3 times monthly. Documentation showed the Chaplain/Bereavement Coordinator, and Physician electronically signed the form on 9/7/22 and 9/14/22, respectively. However, there was no documented evidence when the above physicians order was obtained. On 11/30/23 at 1100 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. 4. Review of Patient 10s closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 4/14/22. The patient was certified for hospice service during the certification period from 10/4/22 to 12/2/22. The Start Frequency Order (undated) showed starting 7/28/22 to 11/18/22, chaplain services were declined. Documentation showed the Chaplain/Bereavement Coordinator, and Physician electronically signed the form on 10/11/22 and 10/18/22, respectively. However, there was no documented evidence when the above physicians order was obtained. On 11/30/23 at 1120 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. 5. Review of Patient 5's closed clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/23/22. The patient was certified for hospice services during the certification period from 12/23/22 to 3/22/23. The Frequency Order (undated) cited Chaplain services once a month from 12/27/22 to 2/17/23. Documentation showed the Chaplain/Bereavement Coordinator and Physician electronically signed the form on 12/27/22 and 1/3/23, respectively. However, there was no documented evidence when the physicians order was obtained. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 6. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 12/1/22 to 1/29/23. The Frequency Order (undated) showed the patient declined Chaplain Services from 2/10/22 to 12/19/22. Documentation showed the Chaplain/Bereavement Coordinator and Physician electronically signed the form on 10/11/22 and 10/18/22, respectively. However, there was no documented evidence when the physicians order was obtained. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 7. Review of Patient 9s closed clinical record was initiated on 11/20/23. The clinical record showed the SOC was 5/11/23. The patient was certified for hospice services during the certification periods from 11/7/22 to 1/5/23 and 1/6/23 to 3/6/23. The Frequency Order (undated) showed the patient declined Social Services from 5/14/22 to 1/22/23. Documentation showed the LVN and Physician electronically signed the form on 11/30/22. However, there was no documented evidence when the physicians order was obtained. On 11/30/23 at 1034 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the discharge summaries were complete for six of six sampled discharged patients (Patients 2, 3, 4, 5, 6, and 7). This failure created the risk of not identifying the patients needs to ensure continuity of care after being discharged from the hospice services. --- Findings: Review of the hospices P&P titled Discharge from Hospice Program dated May 2022 showed when a patient is discharged, transferred, or referred to another organization, relevant information will include the physical and psychosocial status at the time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up; and summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services. 1. Review of Patient 2's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 6/15/19. The patient was certified for hospice services during the certification period from 1/25/23 to 3/25/23. The patient was discharged on 3/1/23. Review of the closed clinical record showed a discharge summary was completed on 3/1/23. However, it was incomplete and did not include the patients physical and psychosocial status at the time of discharge; the summary of care provided; and progress towards achieving the goals as per the hospice's P&P. On 11/30/23 at 0950 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 2. Review of Patient 4's closed clinical record was initiated on 11/14/23. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification period from 12/29/22 to 2/26/23. The patient was discharged on 1/11/23. Review of the closed clinical record showed a discharge summary was completed on 1/12/23. However, it was incomplete and did not include the patients physical and psychosocial status at the time of discharge; the summary of care provided; and progress towards achieving the goals as per the P&P. On 11/30/23 at 1005 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 3. Review of Patient 5's closed clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/23/22. The patient was certified for hospice services during the certification period from 12/23/22 to 3/22/23. The patient was discharged on 2/17/23. Review of the closed clinical record showed a discharge summary was completed on 2/17/23. However, it was incomplete and did not include the patients physical and psychosocial status at the time of discharge; the summary of care provided; and progress towards achieving the goals as per the P&P. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 4. Review of Patient 7's closed clinical record was initiated on 11/16/23. The clinical record showed the SOC was 2/4/22. The patient was certified for hospice services during the certification period from 12/1/22 to 1/29/23. The patient was discharged on 12/19/22. Review of the closed clinical record showed a discharge summary was completed on 12/19/23. However, it was incomplete and did not include the summary of care provided and progress towards achieving the goals as per the P&P. On 11/30/23 at 1020 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding. 5. Review of Patient 3's closed clinical record was initiated on 11/14/23. The closed clinical record showed the SOC was 6/16/22. The patient was certified for hospice services during the certification period from 10/14/22 to 12/12/22. The Visit Note-Patient Care Summary for Live Discharges dated 11/15/22, showed the family requested for transfer to another hospice provider. Documentation showed the discharge summary included current POC and medication list. * However, the discharge summary was incomplete as there was no documented evidence of the summary of the patient's stay including treatments, symptoms, and pain management. On 11/30/23 at 1100 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding. 6. Review of Patient 6's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 1/4/23. The patient was certified for hospice service during the certification period from 1/4/23 to 4/3/23. The patient was discharged on 3/2/3. The Visit Note-Patient Care Summary for Live Discharges dated 3/2/23, showed the family requested to transfer back to the previous provider. Documentation showed the discharge summary included current POC and medication list. * However, the discharge summary was incomplete as there was no documented evidence of the summary of the patient's stay including treatments, symptoms, and pain management. On 11/30/23 at 1050 hours, an interview and concurrent closed clinical record review was conducted with the Director of HR. He was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure care and services were provided in accordance with the POCs for two of 11 sampled patients (Patients 5 and 6) who resided in the SNF, creating the risk of not providing appropriate, consistent, and quality care to this patient. --- Findings: 1. Review of Patient 6's closed clinical record was initiated on 11/20/23. The closed clinical record showed the SOC was 1/4/23. The patient was certified for hospice service during the certification period from 1/4/23 to 4/3/23. The patient resided in a SNF. The patient was discharged on 3/2/23. a. The Physician Order-Admit to Hospice dated 1/4/23, showed to administer oxygen at 2 liters per minute via nasal cannula continuously. The SN note dated 1/6/23, showed the patient was on oxygen at 2.5 liters per minute via nasal cannula. The SN note dated 1/12/23, showed the patient was on oxygen at 2.5 liters per minute via nasal cannula. * However, the amount of oxygen administered to the patient was not consistent with the POC. b. The IDG Meeting Note date 1/17, 1/31, and 2/14/23, showed MSW visit 1 M (one time a month) and 2 PRN visits for psychosocial support. Review of the clinical record showed the initial comprehensive psychosocial assessment was completed on 1/6/23. However, there was no documented evidence a MSW visit was conducted for February 2023 instead of one visit per month as per the POC. On 11/30/23 at 1050 hours, an interview and concurrent clinical record review was conducted with the Director of HR. He was informed and acknowledged the findings. 2. Review of Patient 5's closed clinical record was initiated on 11/15/23. The clinical record showed the SOC was 12/23/22. The patient was certified for hospice services during the certification period from 12/23/22 to 3/22/23. The patient resided at a SNF. The IDG Meeting Note dated 12/29/22, cited Chaplain visits once a month. Review of the Progress Notes dated 1/26 and 2/8/23, showed the Chaplain attempted to call the patient, no available. However, review of the clinical record showed no documented evidence the Chaplain visited the patients home throughout the certification period as cited in the POC. On 11/30/23 at 1016 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.

Observed in Emergency Management Session. During review of the Emergency Management plan and discussion with the Administrator Designee present the surveyor noted that the organization had taken part in the table top Great Shake Out 10/20/22. There was a sign in sheet for staff who participated. An evaluation of the drill document had been started; titled and some boxes check, however it was not completed. For example 2 sections were not completed including evaluation of exercise and any opportunities for improvement. This was confirmed with the Administrator Designee present.

Observed in Record Review. In 1 of 2 patient records reviewed, it was noted that the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. For example, in record DC#3 the MSW first made contact with the patient and family on day 11 and visited with them on day 14. This was confirmed with the Administrative Designee present.

Observed in Record Review. In 2 of 2 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. The assessment did not include the patient’s need for physical, psychosocial, emotional, and spiritual care, including the following: The need for bereavement services to offer support to the patient, family, or other caregivers. There was no documented bereavement assessment in the charts for RR#2 and DC#3 as discussed with the Administrator Designee.

Observed in Record Review. In 1 of 2 patient records reviewed, for deceased patients the surveyor noted that the patient record was not complete and accurately documented. For example record DC#2 the death visit was completed by a LVN, who documented SN noticed MD name and RNCM. On discussion with the LVN, she reported that noticed should be notified and had not pronounced the patient death. She stated that she had called the physician from the home, reported the findings of no VSs and fixed and dilated pupils and the physician pronounced the patient death. This was not documented. This was confirmed with the RN case manager and Administrator Designee/LVN present.

Observed in Record Review. In 2 of 2 records that included spiritual counselor, charts RR#2 and DC#3, the Chaplain goals were not time based. There were no records with MSW services ordered. This was discussed with the Administrator Designee and RN case manager.

Observed in Patient Home. In 1 of 1 home visits conducted, it was noted that the organization did not implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. For example during HV#1 the nurse was observed using purple top Sani wipe to disinfect the equipment prior to returning it to the nursing bag. The Sani wipe packaging and IFU stated that a 2 minute wet time was required and the nurse did not observe the wet time, but wiped the equipment and immediately placed it in the nursing bag. Observed in Patient Home. In 1 of 1 home visits conducted, the organization had not implemented standard precautions to reduce the risk of infection. During HV#1, the clinician put on gloves upon entering the patient room and wore the same gloves throughout the entire visit; touched items in the patient's environment, touched the patient, the RN brushed her hair back from her face, removed socks, disinfected equipment and returned it to the equipment bag entering the bag multiple times all while wearing the same pair of gloves. The RN removed the gloves upon leaving the visit at the door to the patient's room with no hand hygiene upon glove removal. The organizational Hand Hygiene policy required hand hygiene prior to contact with the patient's intact skin, after contact with inanimate objects in the vicinity of the patient, and after removal of gloves. This was discussed with the Alternate Administrator.

Observed in Document Review. The organization had not documented an annual review of the hospice program as required by California law. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.54

Observed in HR File Review. In 4 of 6 HR files reviewed, Staff competence was not assessed and documented annually as required by organization policy. There were no annual competencies in the files for the RN/DPCS/Administrator, RN case manager, MSW and Chaplain. This was confirmed with the HR manager present. He stated that the previous surveyor had explained that they could change the policy or perform the annual competencies and they had planned to change the policy, but it had not been done.

Observed in Record Review. In 2 of 2 patient records reviewed, that included patient's who were discharged or transferred, the organization did not provide information about the care, treatment, or services provided for the patient to other service providers who will provide the patient with care, treatment, or services. For example in records DC#3 a transfer and DC#1 a discharge of extended prognosis the discharge summary did not include a summary of the patient's stay, including treatments, symptoms, and pain management. This was confirmed with the RN case manager and Administrator Designee present.

Observed in Individual Tracer. It was found on HV#1 of 1 that the nurse did not perform effective medication reconciliation . The surveyor asked about the comfort kit left in the home and the care giver brought the kit from the refrigerator. The label on the front of the Comfort Kit had an expiration date of 8/2022. Upon inspection of the medications inside all the medications had expired 8/2022. This was verified with the RN on the visit.

Observed in Record Review. The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. Unable to review MSW goals as there were no patients who had an MSW t the time of this survey. This was verified by the Administrator.

Observed in Emergency Management Session. The Emergency Operations Plan, including the communication plan, had not been reviewed and updated at least every two years. There was no documentation to support that a review had occurred and the plan had been updated.

Observed in Emergency Management Session. The organization had not prioritized their list of potential emergencies identified in the hazard vulnerability. Observed in Emergency Management Session. The organizations EOP did not address response procedures relative to patient care. Rather the response portion of the plan spoke to individual rather than organizational responses such as Remain calm, Follow instructions of designated individuals, Slow down and avoid strenuous activities.

Observed in Emergency Management Session. The organization's written Emergency Operations Plan (EOP) did not describe the recovery strategies, actions, and individual responsibilities necessary to restore the organization’s care, treatment, or services after an emergency. Recovery strategies were not organizationally specific. Recovery strategies in the plan included items such as for earthquakes, Check yourself for injuries before checking others. Watch out for fallen power lines or broken gas lines and report them to the utility company immediately. Observed in Emergency Management Session. The Emergency Operations Plan did not describe the patient population served by the organization and the extent to which additional populations may be cared for during an emergency based on the organization’s capabilities (staff, space, supplies, equipment) as discussed with the Alternate Administrator.

Observed in Emergency Management Session. The organization did not have a process in the EOP for cooperation and collaboration with the local, state, tribal, regional, and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation.

Observed in Emergency Management Session. The Emergency Operations Plan did not describe the following: How the organization will obtain and replenish nonmedical/office supplies that will be required in response to an emergency. Observed in Emergency Management Session. The Emergency Operations Plan did not describe how the organization will obtain and replenish medications and related supplies that will be required in response to an emergency.

Observed in Emergency Management Session. The Emergency Operations Plan did not describe how the organization informs state and local officials of any on-duty staff they are unable to contact. Observed in Emergency Management Session. The EOP did not describe how the organization will inform state and local emergency preparedness officials before, during, and after emergencies on the following: Patients the organization is unable to contact (to determine service needs).

Observed in Emergency Management Session. The EOP did not describe how the organization will inform state and local emergency preparedness officials before, during, and after emergencies on the following: patients in need of evacuation.

Observed in Emergency Management Session. The Emergency Operations Plan did not describe how state and federally designated health care professionals will be incorporated into the staffing strategy for addressing a surge in needs during an emergency. Observed in Emergency Management Session. The Emergency Operations Plan did not describe how the organization will identify staff and authorized volunteers during emergencies.

Observed in Emergency Management Session. The Emergency Operations Plan did not describes the following: The organization's arrangements with other organizations in the event that it cannot serve its own customers as the result of an emergency.

Observed in Emergency Management Session. The EOP did not describe the following: The organization’s primary and alternate means of communicating with staff and federal, state, tribal, and local emergency management agencies;

Observed in Environment of Care Session. The EOP did not describe: Process for communicating information about the general condition and location of patients under the organization’s care to public and private entities assisting with disaster relief.

Observed in HR File Review. In 3 of 6 HR files reviewed, The organization had not provided emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at least every two years. There was no Emergency plan education documented in the HR files for the MSW, Chaplain and Medical Director.

Observed in Emergency Management Session. The organization had not conducted an exercise to test the emergency plan at least annually as confirmed with the Alternate Administrator. The last drill performed was an office building based earthquake drill that did not include the required elements of the standard.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice had not respected the patient’s right to choose an attending physician. In the chart for HV#1, the consent form which documented the patient's choice of either their choice of physician or no choice, the patient had indicated he wanted to choose his attending physician, however there was no documentation to indicate who the patient's chosen physician was. The hospice physician was acting as the patient's attending physician. This was discussed with the Alternate Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician, had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the chart for HV#1, there was no initial MSW assessment completed during the 5 days after election of hospice care, though the order was on the plan of care (POC), though no indication why the assessment did not occur. The first documented MSW assessment occurred four months post discharge. In the chart for RR#4, the MSW did not complete an initial assessment. This was discussed with the Alternate Administrator. Observed in Record Review. In 1 of 11 patient records reviewed, In the chart for RR#8, the Chaplain was on vacation during the time of the patient's admission, so the assessment was not completed within the 5 day timeframe.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. The assessment did not include the patient’s need for physical, psychosocial, emotional, and spiritual care, including the following: Survivor risk factors, such as the nature of the relationship with the patient, circumstances surrounding the death, behaviors before and after the death, availability of coping mechanisms, and potential for pathological grief reactions. There was no documented bereavement risk assessment as part of the initial comprehensive assessment in the charts for HV#1 and HV#3 as discussed with the Alternate Administrator.

Observed in Record Review. In 9 of 11 patient records reviewed, the update of the comprehensive assessment was not based on changes that had taken place since the initial assessment and did not include information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. In the charts for HV#1 and HV#2 the Interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. There was some progress toward goals in the nursing IDT notes, however none for the Spiritual Care nor MSW goals. In the chart for HV#3, the goal pt/CG will verbalize understanding of oxygen safety including all elements from oxygen safety checklist by second visit after oxygen order is obtained.” - remains on the current plan from admission more than 4 months ago. In the chart for RR#4, the nursing staff were providing care to a coccyx wound, yet the plan of care was not updated with interventions/goals for this new problem. In the charts for RR#1, RR#2, RR#3, RR#6, RR#7 there was not documented progress toward goals. This was discussed with the Alternate Administrator. Observed in Record Review. In 8 of 11 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. In the charts for HV#1 and HV#2, there was no input from the MSW in any IDT meeting for the current or previous benefit periods. In the chart for HV#3, there are no notes/input from any discipline regarding progress toward goals for the most recent IDT's prior to the start of the survey. In the chart for RR#1, in the IDT meeting conducted on the same day as the first day of the last benefit period, there is no documented input from any discipline. In the next IDT note, there is input only from nursing. In the chart for RR#3, there is no documented input from any discipline in IDT meeting number 2. In the charts for RR#2, RR#3, RR#4, RR#7 there was no input from the MSW in the IDT meetings. In the chart for RR#6, there was no documented input from any discipline in the IDT prior to the most recent recertification period.This was discussed with the Alternate Administrator.

Observed in Record Review. In 4 of 11 patient records reviewed, the patient record was not complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. In the chart for HV#2, the RN documented that the patient is using ABHR gel; no order is found for this. It is not on the plan of care. In the chart for HV#3, there was an order for evaluation and treatment of cancerous lesion on left shin The SN visit that date and subsequent visit indicate no skin lesions. In the chart for RR#4, during a July SN visit, the skin area of the SN assessment indicated the skin was intact, yet the narrative indicated there was a coccyx wound. The RN cleansed the area with Normal Saline and covered it with Duoderm to protect it. A wound/podiatry consult was first ordered on 6/2 and again 6/20. Visits previously and subsequently indicate the patient's skin was intact. The documentation was not clear to determine why those orders were requested/obtained. In the chart for RR#5, the RN indicated on the first IDT update that a Fentanyl patch had been added to the patient. There was no indication in the chart that this information was accurate. In the last IDT note, the RN indicated that the family had benefitted from Chaplain and MSW support. No MSW visits had been documented nor ordered. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RR#1, the MSW and Chaplain goals were not time based. This was discussed with the Alternate Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for HV#1, there was no frequency of visits on the POC for the Chaplain who was providing monthly contacts via telehealth visits. In the chart for RR#2, the RN indicated in the IDT update prior to the beginning of the final benefit period that PT continues benefiting Pt in maintaining functional abilities, preventing falls/injuries, as well as supporting quality of life. There are no frequency orders on the POC for PT. This was discussed with the Alternate Administrator.

Observed in Record Review. In 7 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for HV#1, Ensure that the patient was using daily as confirmed in SN notes and during the home visit, was not on the POC. In the chart for HV#2, there were no interventions for the MSW visits which were ordered 1-3 times monthly. Additionally, the patient was on Diclofenac Sodium 1% Gel apply LIBERAL AMOUNT 4 times daily to affected areas upon admission. Four months later, the RN obtained an order for Voltaren 1% gel, 1 GM once daily prn pain. The original order failed to address recommended dosages and it did not appear that the team realized that the patient was already on the maximally recommended dosage frequency for Voltaren/Diclofenac when the prn dose was ordered. In the chart for HV#3, the patient was assessed to be at high risk for falls, yet there were no fall prevention interventions on the POC. In the chart for RR#2, the RN indicated in the IDT update prior to the beginning of the final benefit period that there was an order for topical cortisone. This medication was not on the hospice plan of care. Also mentioned that PT continues benefiting Pt in maintaining functional abilities, preventing falls/injuries, as well as supporting quality of life. There are no interventions on the hospice POC for PT. In the chart for RR#3, there was an order to refer the patient for a wound clinic consult for a lesion on the patient's back. The RNs report providing wound care to the patient, however no wound care orders are documented in the record.In the chart for RR#3, there was an order to refer the patient for a wound clinic consult for a lesion on the patient's back. The RNs report providing wound care to the patient, however no wound care orders are documented in the record.In the chart for RR#4, the patient was using Ensure which was not included on the POC. Additionally, the nurses were providing wound care to a coccyx pressure ulcer, however there was no order for care on the POC. The patient was assessed to be at high risk for pressure ulcer development, yet there were no interventions related to this risk on the POC, yet teaching had occurred. In the chart for RR#7, the wound care order on initial POC was missing a frequency. Additionally, the patient had a history on pressure ulcers, the RN taught the caregivers pressure ulcer prevention techniques, yet these interventions were not on the POC. In the most recently documented SN note in the chart the RN documented Wound cleaned with NS, dried with gauze, medihoney applied to the wound bed and foam border sacral dressing applied There was no order for this care documented in the patient record. This was discussed with the Alternate Administrator.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for HV#1, the MSW was ordered monthly. There is no documentation of any contact with the patient or PCG for more than 6 months. In the chart for HV#2, MSW was ordered 1-3 times monthly. There are only two documented MSW visits since admission seven months prior to this survey. SN visits were ordered weekly. During the current benefit period, two weeks passed between SN visits. In the chart for RR#4, the aide was ordered twice weekly yet the patient was being seen weekly. In the chart for RR#3, the aide was ordered twice weekly from the admission. Aide services did not start until week three of the benefit period. In the charts for RR#6 and RR#7, Chaplain visits/contacts were ordered monthly on the POC; no visit/contacts have been made for more than 6 months. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, all disciplines that provide care, treatment or services to the patient had not collaborated in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In the chart for RR#4, the nursing staff provided wound care, however there was no indication the physician was contacted to inform him that the patient had developed a wound. Additionally, the patient was discharged due to extended prognosis, however there was no documentation in the chart to indicate the team collaborated on nor planned the patient's discharge. This was discussed with the Alternate Administrator.

Observed in Data Session. The organization had not maintained documentation of the quality assessment and performance improvement program and was not able to demonstrate its operation. While the leaders present during the survey were able to speak to the program, there was no documentation available to demonstrate the compliance.

Observed in Data Session. The organization had not documented an annual evaluation of the QAPI program. Quarterly monitoring was documented which did not include any performance improvement projects. This was discussed with the Alternate Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented standard precautions to reduce the risk of infection. During HV#2, the clinician did not wash her hands after arrival at the home, touching items in the patient's environment prior to touching the patient inconsistent with organizational policy which required hand hygiene prior to contact with the patient's intact skin. This was discussed with the Alternate DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. The assessment did not include the patient’s need for physical, psychosocial, emotional, and spiritual care, including the following: Patient and family spiritual orientation, including their desire for the involvement of a religious group; Spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness. In the charts for RR#3 and HV#3, the patient refused MSW and Spiritual Care disciplines and the RN assessment did not include the above elements as discussed with the Alternate Administrator.

Observed in HR File Review. The hospice aide had not successfully completed a competency evaluation before providing patient care. The initial competency evaluation form in the file for the aide did not have the required elements signed off as competent. This was discussed with the Alternate Administrator and HR Manager.

Observed in HR File Review. A registered nurse had not performed the competency evaluation of a home health aide or hospice aide. The aide competency evaluation was signed by the LVN. Per discussion with the HR Manager and Alternate Administrator, they were unaware of the requirement.

Observed in HR File Review. The hospice aide had not participated in at least 12 hours of in-service training during each 12-month period. There was no in-service education documentation for the hospice aide for 2020, 2021 and 7 hours documented so far in 2022 as confirmed with the HR Manager who was unaware of the requirement.

Observed in Tracer Activities. The organization had not documented an annual review of the hospice program as required by California law. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100, §418.113, §418.60, §418.114, §418.56, §418.58, §418.54 and §418.104.

Observed in HR File Review. In 5 of 6 HR files reviewed, Staff competence was not assessed and documented annually as required by organization policy. There were no annual competencies in the files for the LVN/Alt. Administrator, Aide, Medical Director, MSW and Chaplain.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record did not contain specific notes on care, treatment and services. In the chart for RR#2, PT evaluation was ordered approximately 7 months prior to the patient's discharge and continued into the last benefit period per the IDT notes. There were no PT notes in the patient chart. Additionally, the chart indicated the patient was discharged due to a fall and the patient went to the ED to seek treatment for a possible fracture. There was no documentation to indicate how the organization was made aware of this change in patient condition. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, all entries in the patient record were not legible, clear, complete, and appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. In the chart for RR#5, there were multiple SN clinical visit notes which did not include the name and discipline of the rendering clinician. This was confirmed with the Alternate DPCS and Alternate Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, when the care of the patient was transferred to another Medicare/Medicaid-certified facility, the hospice had not provided the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. In the chart for RR#2, the patient revoked the hospice benefit to pursue evaluation in a hospital emergency department. There was no discharge summary in the patient record nor any documentation that any information about the patient was provided to the receiving organization as confirmed with the Alternate Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, when a patient was discharged or transferred, the organization had not given information about the care, treatment, or services provided to the patient to other service providers who will provide the patient with care, treatment, or services. In the chart for RR#4, the patient discharged for extended prognosis, the discharge summary did not include a summary of the patient's stay, including treatments, symptoms and pain management. In the chart for RR#2, there was no discharge summary This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, at the time when controlled medications are first ordered, the hospice had not provided a copy of its written policies and procedures on the management and disposal of controlled medications to the patient or the patient’s representative and family. In the chart for HV#1, there was no documentation this information had been provided to the patient nor the patient's family. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, for a patient who died while on service, staff who provide patient care, treatment, or services did not practice within the scope of their license, certification, or registration and as required by law and regulation. In the chart for RR#1, the patient who died while on service, the death pronouncement was made by the LVN and documented as such. Upon discussion with the Alternate Administrator, this had been organizational practice and they were unaware this was not allowed under California scope of practice for LVN's. Observed in HR File Review. In 3 of 3 HR files reviewed, the organization had not verified and documented the following: Credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This was not done at the time of hire and at the time credentials are renewed. In the file for the Medical Director, RN and LVN/Alternate Administrator, there was no documentation of licensure verification at the time of hire. Upon discussion with the HR Manager, it was verified that he did not keep the documents at the time renewal was verified.

Observed in Record Review. In 2 of 2 patient records reviewed, in which the organization discharged the patient alive, the organization had not provided care, treatment, or services in accordance with regulations. In the chart for RR#4, the patient discharged due to extended prognosis, the NOMNC was provided to the primary caregiver on the date of discharge rather than prior to the discharge. In the chart for RR#2, the patient's revocation form was not found in the record, though the organization does have an established process for obtaining revocation statements. This was discussed with the Alternate Administrator.