Every finding on record at Valerian Home Health and Hospice

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 13 (54%) clinical records reviewed, the agency did not ensure an initial bereavement assessment was completed as part of the comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/05/2026 with a diagnosis of Alzheimer’s disease. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/06/2025 with a diagnosis of senile degeneration of the brain. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/29/2024 with a diagnosis of severe protein calorie malnutrition. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/13/2024 with a diagnosis of Alzheimer’s disease. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/06/2026 with a diagnosis of hemiplegia. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/15/2025 with a diagnosis of Parkinson’s disease. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/11/2026 with a diagnosis of Alzheimer’s disease. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. During an interview and joint clinical record reviews on 04/30/2026, the Administrator/Alternate Director of Patient Care Services (DPCS)/Registered Nurse (RN) stated that the clinical records were missing the initial bereavement assessment. The Administrator/Alternate DPCS/RN stated, "The initial bereavement assessment wasn't completed because it was not being assigned to the Spiritual Counselor (SC)/Bereavement Coordinator (BC) at time of admission. There has been a newly hired SC/BC that has a strong desire to take the bereavement program to the next level."

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed for deceased patients, the agency did not ensure a bereavement plan of care was developed. CLINICAL RECORD 4: The patient death was on 09/30/2025. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. CLINICAL RECORD 5: The patient death was on 09/28/2025. There was no documented evidence in the clinical record that a post-death bereavement plan of care was developed for the bereaved. During an interview and joint clinical record review on 04/30/2026, the Administrator/Alternate Director of Patient Care Services (DPCS)/Registered Nurse (RN) stated that the post-death bereavement plans of care were missing from the clinical records. The Administrator/Alternate DPCS/RN stated, "We hired a new Spiritual Counselor (SC)/Bereavement Coordinator (BC) on 04/06/2026 and orientation is in progress. I just spoke with the SC/BC, and he has a planned process to ensure to check-in with survivors of the two (2) patients that are listed above. He also reported with the next patient death, he has previous experience with this and will complete the post-death bereavement assessment and will develop a post-death plan of care based on survivor needs."

It is required that each patient’s individualized written plan of care reflects patient and family goals, includes all services necessary for the palliation and management of the terminal illness including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, the hospice did not ensure the plan of care reflected patient and family goals with measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 3: The patient elected hospice care on 06/08/2023. The plan of care (POC) dated 06/08/2023 documented the problem "Hard of Hearing" with the goal "SN will assist patient with hearing aid." The goal "SN will assist patient with hearing aid" did not include a measurable outcome. Clinical Record 4: The patient elected hospice care on 06/16/2023. The POC dated 06/16/23 documented the problem "Knowledge deficit related to Hospice Care" with the goal "notify the patient and inform him of his hospice diagnosis." The goal "notify patient and inform him of his hospice diagnosis" did not include a measurable outcome. Clinical Record 2: The patient elected hospice care on 06/12/2023. The POC dated 06/12/23 documented the problem "pain" with the goal "Pain is improving." The goal for pain did not reflect the patient/family goal for pain and did not include a measurable outcome. The Director of Clinical Services was interviewed on 07/05/2023 and confirmed the goals did not include outcomes that were measurable. No further information was provided. CONTINUING REQUIRED ACTION.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and is consistent with the hospice aide training. CONTINUING REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed of patients who received aide services, the agency did not ensure that the aide provided services included in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 06/08/23 with a diagnosis of Malignant Neoplasm of the Prostate. The hospice aide care plan initiated by the Registered Nurse (RN) on 06/08/23 assigned the hospice aide the tasks: shampoo and shower patient on Mondays, Wednesdays, and Fridays. The aide documented the tasks shower and shampoo as completed on Saturday, 06/11/23, and Tuesday, 06/13/23. There was no evidence that the aide care plan was changed. During an interview, the Director of Clinical Services confirmed the aide did not follow the plan of care. No further information was provided. CONTINUING REQUIRED ACTION.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by document review, clinical record review, and interviews with the Director of Clinical Services which revealed issues with the completion of comprehensive assessments in the following areas: Failed to ensure the comprehensive assessment included a complete review of all medications the patient was taking [HCPC.15.I/L530]; Failed to ensure updates to the comprehensive assessments were completed and documented by the IDG [HCPC.17.I/L533]; and Failed to ensure the comprehensive assessment was completed no later than 15 calendar days after the election of the hospice benefit [HCPC.9.I/L523]. The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to identify and meet the care needs of the patients and ensure continuity of care and service coordination.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. 4 of 14 (29%) clinical records reviewed revealed the social worker did not complete the initial comprehensive assessment within 5 days after the election of the hospice benefit. Clinical Record 4: The patient elected the hospice benefit on 3/21/2023. The initial social work assessment was completed on 4/19/2023 which was 29 days after election of hospice care. Clinical Record 5: The patient elected the hospice benefit on 10/11/2022. The initial social work assessment was completed on 10/22/2023 which was 11 days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 3/23/2023. The initial social work assessment was not completed until 4/5/2023 which was 13 days after the election of hospice care. Clinical Record 14: The patient elected the hospice benefit on 11/23/2022. The Initial social work assessment was completed on 12/10/2022 which was 17 days after the election of hospice care. In an interview with the Director of Clinical Services and the Executive Director, it was confirmed there was no documentation found or produced to explain the delays in completing the social work initial comprehensive assessments.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. 2 of 14 (14%) clinical records reviewed revealed that agency did not ensure the patients' plans of care and drug profiles were accurate and updated to include oxygen orders. Agency Policy "Reassessments/Updates to the Comprehensive Assessment" 9.8.1, with the effective revision date of February 2021, stated, "Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying ...patient needs and problems to direct care and services and update the IDG care plan." Agency Policy "IDG Care Planning Process" 9.12.1, with an effective revision date of February 2022, stated, "An individualized written plan of care is developed for each patient ..reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments ...written to include all services necessary for the palliation and management of the terminal illness and related conditions ...symptoms such as ... dyspnea ...drugs and treatments necessary to meet the needs of the patient..." Clinical Record 5: Patient elected the hospice benefit on 10/11/2022. A physician order for oxygen 2 liters per minute (LPM) by nasal cannula (NC) was entered on 2/16/2023 due to a change in patient status. There was no intervention on the plan of care to address the addition of oxygen due to a decline in patient status and oxygen was not added to the patient's list of medications on Plan of Care Orders from 2/22/2023 through 5/18/2023. The physician's order for oxygen was also not included in the updated Plan of Care. Clinical Record 6: Patient elected the hospice benefit on 7/27/2022. During the LPN/LVN Nursing Visit on 4/19/2022, it was documented that patient was on oxygen at 2.5 liters per minute (LPM) via nasal cannula (NC) due to a change in the patient's respiratory status. There was no intervention on the plan of care to address the addition of oxygen due to a decline in patient status and oxygen was not added to the patient's list of medications on Plan of Care Orders from 4/19/2023 through 5/18/2023. The physician's order for oxygen was also not included in the updated Plan of Care. In interviews on 5/24/2023 and 5/25/2023, the Director of Clinical Services confirmed that oxygen was not on the patients' medications profiles or in their Plans of Care/Interdisciplinary Group documentation or updates.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. This standard was not met as evidenced by clinical record review and interview. 14 of 14 (100%) clinical records reviewed revealed the agency did not ensure that patient assessment updates included an evaluation of the patients' responses to care, new or changed orders, medications, or treatments, or progress toward desired outcomes. Agency Policy, "IDG Care Planning Process" 9.12.1 with the effective revision date of February 2022, stated," In order to assure that the care provided is appropriately planned to meet each patient's specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with the patient's needs and goals as a priority." Continuing in the same policy, "...The RN ensures that the plan of care is individualized, updated, and relevant to the needs of the patient/family by: ...documenting and revising patient care goals/objectives in a timely manner...developing and revising patient care goals/objectives in coordination with other members of the IDG." Agency Policy, "Reassessments/Update to the Comprehensive Assessment" 9.8.1 with the effective revision date of February 2021, stated, "Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided...Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services and update the IDG care plan." The agency used the "Updated Plan of Care Order" to document each IDG Meeting. The document was generated every two weeks on the day of IDG. There were no notes from any of the IDG disciplines, no updates on the problems or progress toward goals, and no documentation on the interventions for the identified problems, if interventions were included at all. During the review of all fourteen clinical records, it was revealed that the agency did not ensure that the Plan of Care Orders/Interdisciplinary Group (IDG) Meeting documentation contained any changes that had occurred over the previous two-week period. When the nurse obtained new orders, changed orders or discontinued orders, the updated orders did not flow to the Updated Plan of Care Orders/IDG Meeting documentation. The documentation was the same every 2 weeks. The Social Worker was the only member of the IDG team who was documenting toward the problems/interventions identified or documenting progress toward goals. There was no documentation of Chaplain care plans. Clinical Record 5: For the Plan of Care Order Update/IDG Meeting 2/22/23, problems identified included skin, pain, emotional support, fungal infection. The clinical record include a physician order dated 2/16/23 for oxygen 2 LPM NC and a physician order dated 2/19/23 for albuterol nebulizer treatment every 6 hours as needed for wheezing. 3/15/23 Skilled Nursing Visit documentation: wheezing and nebulizer treatments nail fungal infection. 4/11/23 Skilled Nursing Visit documentation: SOB with moderate exertion, wheezing. There were no updates to the Plan of Care Updates/IDG Meeting problems to identify respiratory issues. None of the physician orders flowed to the updated Plan of Care Orders/IDG Meeting documentation. There was no documentation related to the skin or pain problems identified and no documentation of interventions or progress toward goals. There was no documented evidence of changes or lack of changes in the previous two weeks from the RN, SW, Chaplain. There was no Chaplain care plan. Clinical Record 4: There was no documentation in the clinical record to address any changes or lack thereof from any member of the IDG from one IDG meeting to the next. There was no Chaplain plan of care. Clinical Record 1: The clinical record documentation included a physician order for Bactrim for 5 days to treat a UTI. LPN visit on 4/17/2023 stated, “Pt received initial dose of Bactrim for UTI yesterday.” 5/3/2023 Physician order for wound care to the patient’s right hand twice a week to cleanse with wound cleanse, pat dry, apply skin prep around wound and cover with adaptic and foam border. 5/18/2023 Order for Keppra once every 12 hours. LVN visit documentation 5/22/2023 stated, “…pt had a ‘seizure-like’ episode in the shower this morning.” Wound care order for 5/22/2023 left thumb wound apply triple antibiotic ointment and cover with a band aid during regularly scheduled nursing visits. None of this information nor any of the team members had any contributing documentation on the Updated Plan of Care Orders/IDG Meeting Updates. Specifically, the new orders did not flow over, no documentation related to the wounds, UTI, or seizure activity was included and no new problems were identified. The only update or documentation of progress toward goals was completed by the MSW. For the Plan of Care Order/IDG updates from 4/6/2023 through 5/18/2023, the identified problems at risk for falls, emotional support, funeral plans were the only issues identified or included. Clinical Record 2: RN Skilled Nurse Visit 4/13/2023 documented the patient with intractable chronic pain and Tylenol with Codeine 300/30 every 8 hours PRN for pain since 7/15/2022. Problems List included shortness of breath, risk for falls and emotional support. There was no documentation of a problem, interventions, or goals to address pain. The shortness of breath and risk for falls were identified 8/19/2021. There have been no new problems, no documentation on the shortness of breath or risk for falls and no documentation of progress toward goals since 8/19/2021. None of the Plan of Care Updates/IDG Meetings included any documentation from members of the IDG. There was no documentation of changes/updates or lack thereof from any member of the IDG. Clinical Record 3: The patient’s problem list included fall risk, UTI, potential for skin infection, and emotional support. For the problems fall risk, UTI, potential for skin infection there was no documentation of interventions or progress toward goals. There was no documentation regarding changes or lack of changes in each Plan of Care Update/IDG Meeting from any member of the IDG team. Clinical Record 6: RN Skilled Nurse Visit 2/28/23 documented nonproductive cough identified; order for Robitussin DM 20ml every 4 hours as needed. Physician order 4/18/23: Prednisone dose pack and Azithromycin 500mg QD for respiratory infection. LPN Nurse Visit 4/19/23 documented O2 at 2.5 LPM, “Pt wheezing in lungs throughout. O2 sat on room air at 80%, O2 applied at 2.5 LPM NC and increased O2 sat to 93%.” Problems Identified in the Plan of Care Order Update/IDG Meetings 3/8/23 to 5/18/23 included skin, pain, psychosocial support, emotional support. There was no update to include an identified respiratory problem or interventions. The orders did not update to the IDG Meeting documentation. There was no documentation to address any changes or lack thereof from any member of the IDG, from one IDG meeting to the next. The problems identified: skin, pain, did not have any documentation toward the care plan, interventions, or progress toward goals. There was no documentation of a Chaplain care plan. Clinical Record 14: There was no documentation to address any changes or lack thereof from any member of the IDG, from one IDG meeting to the next. There was no Chaplain care plan. Clinical Record 7: The Plan of Care Order Updates/IDG Meeting documentation included pain, skin, and emotional support problems identified. There was no documentation toward the pain and skin problems and no documentation of interventions or progress toward goals documented from 4/20/2023 to 5/18/2023. There was no documentation in the IDG updates from any of the IDG team members to address changes or lack of changes that had occurred during the previous 2 weeks. There was no Chaplain care plan. Clinical Record 8: Plan of Care Order Updates/IDG Meeting from 4/20/23 to 5/18/23 included no documentation related to the identified problems of pain or skin and no intervention documentation or progress toward goals. There was no documentation in the clinical record to address any changes or lack thereof from any member of the IDG from one IDG meeting to the next. The problems identified: skin, pain, did not have any documentation toward the care plan, interventions, or progress toward goals. There was no Chaplain care plan. Clinical Record 9: There was no documentation in the clinical record to address any changes or lack thereof from any member of the IDG from one IDG meeting to the next. The problems identified: skin, pain did not have any documentation toward the care plan, interventions, or progress toward goals. There was no Chaplain care plan. Clinical Record 10: There was no documentation in the clinical record to address any changes or lack thereof from any member of the IDG from one IDG meeting to the next. Clinical Record 11: There was no documentation in the clinical record to address any changes or lack thereof from any member of the IDG from one IDG meeting to the next. There was no Chaplain care plan. Clinical Record 12: There was no documentation in the clinical record to address any changes or lack thereof from any member of the IDG from one IDG meeting to the next. There was no Chaplain care plan. Clinical Record 13: There was no documentation in the clinical record to address any changes or lack thereof from any member of the IDG from one IDG meeting to the next. There was no Chaplain care plan. In an interview with the Director of Clinical Services and the Executive Director on 5/25/2023, discussion included a review of the current process for updating IDG documentation in the electronic medical record (EMR). It was stated that any new orders over the two weeks in between team meetings did not flow to the updated Plan of Care Order/Meeting documentation. It was also pointed out that the team is not documenting care plan intervention activities. At that time, it was discovered that the practice was for the Director of Clinical Services (DCS) to generate the documentation. Since the DCS does not see the patients, changes are unknown to the DCS and not included in the document. There was a Case Conference binder where documentation from each meeting is placed that included the signatures of the team members that attended the meeting and which patients were reviewed. On some of the patient lists, there were a few handwritten notes next to the patients' names. These notes were not dated, signed, or scanned into the patients' clinical records, and on each page, all the patients reviewed were listed. The Executive Director contacted the EMR vendor to review their recommendations for updating the comprehensive assessments and Interdisciplinary Group Meeting documentation. During this process, the Executive Director discovered an "IDT Meeting" function in which the required updates could be documented in the future. During the review of all fourteen clinical records, it was revealed that the agency did not ensure that the Plan of Care Orders/Interdisciplinary Group (IDG) Meeting documentation contained any changes that had occurred over the previous two-week period, updated problem identification or interventions, new, changed or updated physician order, any response to treatment or the progress toward goals. There was no updated information from the members of the team documenting new or changed assessment findings. There was also no documentation of any interventions on existing identified problems. The Updated Plan of Care Order was how the agency was documenting each IDG Meeting. The document was generated every two weeks on the day of IDG. However, there was no notes from any of the IDG disciplines, no updates on the problems or progress toward goals, and no documentation on the interventions for the identified problems, if interventions were included at all. The agency's policy, "IDG Care Planning Process" 9.12.1 with the effective revision date of February 2022, reads," In order to assure that the care provided is appropriately planned to meet each patient's specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with the patient's needs and goals as a priority." Continuing in the same policy, "...The RN ensures that the plan of care is individualized, updated, and relevant to the needs of the patient/family by: ...documenting and revising patient care goals/objectives in a timely manner...developing and revising patient care goals/objectives in coordination with other members of the IDG." The agency policy, "Reassessments/Update to the Comprehensive Assessment" 9.8.1 with the effective revision date of February 2021, reads, "Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided...Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services and update the IDG care plan." In an interview with the Director of Clinical Services and the Executive Director on 5/25/2023, a discussion reviewed their current process within their Electronic Medical Record (EMR). It was reviewed that any new orders over the two weeks in between team meetings did not flow to the updated Plan of Care Order/Meeting documentation. It was also pointed out that the team is not documenting care plan intervention activities. At that time, it was discovered that the practice was for the Director of Clinical Services (DCS) to generate the documentation. Still, since the DCS does not see the patients, changes are unknown to the DCS and not included in the document. There was a Case Conference binder where documentation from each meeting is placed that included the signatures of the team members that attended the meeting and which patients were reviewed. On some of the patient lists, there were a few words handwritten next to the patients' names. These notes were not dated, signed, or scanned into the patient's clinical records, and on each page, all the patients reviewed were listed. The Executive Director reached out to the EMR in order to review what their recommendations were for updating the comprehensive assessments and Interdisciplinary Group Meeting documentation. During this whole process, the Executive Director discovered an "IDT Meeting" function in which the required updates could be documented in the future.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. 4 of 14 clinical records reviewed revealed the agency did not ensure that staff provided services as ordered on the plan of care. Clinical Record 4: The patient elected the hospice benefit on 3/21/2023. The patient received an initial visit from the Chaplain on 3/21/2023. The Plan of Care Order dated 3/24/2023 listed under the heading of Services that the Chaplain would visit the patient once a week. From 3/24/2023 to 4/20/2023, the Chaplain made no visits, thus not meeting the ordered frequency. In the Plan of Care dated 4/20/2023, under the heading of Services, the order for Chaplain visit frequency was changed to once a quarter. Clinical Record 5: The patient elected the hospice benefit on 10/11/2022. Plan of Care Orders dated 2/8/2023, 2/22/2023, 3/8/2023, 3/22/2023, 4/5/2023, 4/19/2023, 5/3/2023, and 5/18/2023 stated frequency orders for nursing visits to be completed two times a week. During the time period from 2/16/2023 to 5/9/2023, the nurse visited the patient once a week only. Clinical Record 6: The patient elected the hospice benefit on 7/27/2022. The Plan of Care Orders dated from 2/22/2023 to 5/18/2023 indicated the nurse frequency was five times a week. From the week of 2/19/2023 to 5/20/2023, nursing visits were performed one time per week. Clinical Record 9: The patient elected the hospice benefit on 2/26/2021. The Plan of Care Orders from 4/6/2023 through 5/18/2023 set the nursing visit frequency at once a week. From 4/17/2023 through 5/19/2023, the patient received nursing visits three times a week. During an interview with the Director of Clinical Services on 5/24/2023 and 5/25/2023, no additional information or documentation was provided, and it was confirmed that services were not provided at the ordered frequencies.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 13 of 14 (93%) clinical records reviewed revealed the agency failed to ensure the patients’ individualized written plans of care included newly identified problems and planned interventions based on updated findings from the comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 3/23/2023. In the LPN/LVN Skilled Nursing visit dated 4/17/2023, the nurse documented, "Pt received initial dose of Bactrim for UTI yesterday.” There was a physician order dated 4/16/2023 for Bactrim for five days for a urinary tract infection. In the plan of care update dated 4/20/2023, no updated problem for the urinary tract infection was identified and there were no interventions added to the updated plan of care. There were two physician orders for wound care: one dated 5/3/2023 for wound care to the right hand twice a week and the one dated 5/22/2023 for wound care to the left thumb wound. As of 5/24/2023, the patient’s problems had not been updated to include the documentation of the wounds. In the LPN/LVN Skilled Nursing Visit dated 5/22/2023, the nurse documented, "...pt had a seizure like episode in the shower this morning." On 5/18/2023, there was a new order for Keppra 500mg every 12 hours. As of 5/24/2023, there had been no update to include a newly identified problem or intervention related to seizure activity. Clinical Record 2: The patient elected the hospice benefit on 8/19/2021. The Plan of Care Orders dated 4/6/2023, 4/20/2023, 5/4/2023, and 5/18/2023 included the Chaplain visit frequency for one time a month. The Chaplain visit dated 4/19/2023 stated, "Purpose of the Visit: To decrease social deprivation. To encourage spiritual and emotional support when necessary.” In the problem list identified in the Interdisciplinary team updates from 4/6/2023 - 5/18/2023 there was no identified Chaplain visit plan or interventions. Additionally, in the RN Skilled Nursing Assessment dated 4/13/2023, the nurse documented the patient "...with intractable chronic pain-denies need for intervention at this time." The assessment included documentation that the pain was generalized and always present. In the Plan of Care Updates from 4/6/2023 to 5/18/2023, the only problems identified were shortness of breath, risk for falls, and emotional support. There was no pain problem identified and no interventions included related to pain. Clinical Record 3: The patient elected the hospice benefit on 12/21/2022. In the Plan of Care Orders dated 4/19/2023, 5/4/2023, and 5/18/2023 the Chaplain visit frequency was once a month. In the Chaplain/Counselor Visit on 4/19/2023, in the "Notes" section, it was documented that "Purpose of Visit: To provide a Ministry of Presence. To bring spiritual and emotional support to both family and patient." In the Problem List identified in the Interdisciplinary Team updates from 4/19/2023 through 5/18/2023, there was no identified Chaplain visit plan or interventions. Clinical Record 4: The patient elected the hospice benefit on 3/21/2023. The initial Chaplain visit was performed on 3/21/2023 in the Chaplain/Counselor Assessment. The Chaplain documented under the section "Continuing Care: Yes, Chaplain services were needed.” In the Chaplain/Counselor Visit on 4/21/2023, the only sections of the assessment completed were "Religion" and "Spiritual Perspectives." In the "Notes" section, the Chaplain/Counselor documented, "Purpose of Visit: To provide a Ministry of Presence. To tend the spiritual and emotional needs as much as possible." In the patient's list of problems during the IDT meetings from 3/24/2023 to 5/18/2023, the only problems and interventions identified were Pain, Emotional - both created by the RN. On 4/19/2023, the Social Worker identified Emotional Support/Companionship Needs with the goal, "Social worker will visit pt to reduce isolation while in facility." There was no identified Chaplain visit plan or interventions. Clinical Record 5: The patient elected the hospice benefit on 10/11/2022. In the Plan of Care Orders dated 2/8/2023 to 5/18/2023, the frequency of Chaplain visits was once a month. The Chaplain/Counselor Visit note dated 2/23/2023 was blank. The Chaplain/Counselor Visit notes dated 3/23/2023, 4/8/2023, and 5/18/2023 stated, "Purpose of the Visit: To decrease social deprivation. To encourage spiritual and emotional support when necessary. In the Problem List identified in the Interdisciplinary Team updates from 2/22/2023 through 5/18/2023, there was no identified Chaplain visit plan or interventions. Additionally, in the LPN/LVN Skilled Nurse Visit dated 2/16/2023, the nurse documented that the patient's oxygen saturation had dropped to 86% on room air. The nurse received a physician order dated 2/16/2023 for oxygen to be provided to the patient at 2 liters per minute (LPM) as needed. Another physician's order was received on 2/19/2023 for Albuterol nebulizer treatments every 6 hours as needed for wheezing. The RN Skilled Nurse Visit dated 2/21/2023 indicated that the patient was on 2LPM oxygen during the visit and that the patient had "loud wheezing in her lungs bilaterally." In the RN Skilled Nurse Visit dated 4/11/2023, in the narrative portion of the note, the nurse documented, "Pt's lungs sound better in regard to the wheezing ...." The problem list for the patient was not updated to reflect the change in the patient's assessment and there were no planned interventions addressing the patient's need for oxygen and nebulizer treatments from 2/22/2023 through 4/19/2023. Clinical Record 6: The patient elected the hospice benefit on 7/27/2022. The Chaplain/Counselor Visit notes dated 2/20/2023, 3/23/2023, and 4/19/2023 stated, "Purpose of the Visit: To decrease social deprivation. To encourage spiritual and emotional support when necessary. In the Problem List identified in the Interdisciplinary Team updates from 2/22/2023 through 5/18/2023, there was no identified Chaplain visit plan or interventions. Additionally, in the LPN/LVN Skilled Nursing Visit dated 4/19/2023, the nurse documented, "Pt wheezing in lungs throughout. O2 sat on room air at 80%. O2 applied at 2.5L NC increased O2 sat to 93%. The nurse also documented that the patient "was not alert or verbal during visit” and had refused food and drink since the previous day (4/18/2023). Physician orders were received on 4/19/2023 for a Prednisone dose pack and Azithromycin 500mg daily for a respiratory infection. The problem list for the patient was not updated to reflect the change in the patient's assessment and there were no planned interventions addressing the patient's respiratory infection in the Plan of Care updates from 4/5/2023 through 4/19/2023. Clinical Record 7: The patient elected the hospice benefit on 10/26/2022. Per the Plan of Care Order dated 4/20/2023, the Chaplain visit frequency was once a month. In the 4/23/2023 visit note, the Chaplain/Counselor Visit documented, "Purpose of the Visit: to tend to pt's spiritual and emotional needs." The Problem List identified in the Interdisciplinary Team updates from 4/19/2023 through 5/18/2023, did not include documentation of a Chaplain visit plan or interventions. Clinical Record 8: The patient elected the hospice benefit on 7/18/2022. The Plan of Care Orders 4/19/2023 through 5/18/2023 stated the Chaplain visit frequency was once a month. In the 4/18/2023 visit note, the Chaplain/Counselor Visit on 4/18/2023, documented, "Purpose of Visit: To decrease social isolation. To provide ministry of presence.” The Problem List identified in the Interdisciplinary Team updates from 4/19/2023 through 5/18/2023, did not include documentation of a Chaplain visit plan or interventions. Clinical Record 9: The patient elected the hospice benefit on 2/26/2021. Plan of Care Orders from 4/6/2023 through 5/18/2023 stated the Chaplain visit frequency was once a month. In the 4/16/2023 visit note, the Chaplain/Counselor Visit documented, "Purpose of Visit: To render spiritual and emotional support to patient and family. To provide ministry of presence.” The Problem List identified in the Interdisciplinary Team updates from 4/6/2023 through 5/18/2023, did not include documentation of a Chaplain visit plan or interventions. Clinical Record 10: The patient elected the hospice benefit on 4/4/2023. The Plan of Care Order/IDG Meeting dated 4/6/2023 stated the Chaplain visit frequency was once a month. In the 4/23/2023 visit note, the Chaplain/Counselor documented, "Purpose of Visit: To tend to patient spiritual and emotional needs when necessary." The Problem List in the Plan of Care Orders/Interdisciplinary Group Updates from 4/6/2023 to 5/18/2023 did not include documentation of a Chaplain visit plan or interventions. Clinical Record 12: The patient elected the hospice benefit on 9/20/2022. The Plan of Care Order/IDG Meeting dated 4/6/2023 stated the Chaplain visit frequency was once a month. The Problem List in the Plan of Care Orders/Interdisciplinary Group Updates from 4/6/2023 to the time of the patient's death on 4/30/2023 did not include documentation of the Chaplain visit plan or interventions. Clinical Record 13: The patient elected the hospice benefit on 2/17/2023. The Plan of Care Orders from 2/17/2023 through 3/8/2023 stated the Chaplain visit frequency was monthly. In the Chaplain/Counselor Assessment on 2/17/2023, the Chaplain/Counselor stated, "Continuing care need? Yes." The Problem List identified in the Interdisciplinary Team updates from 2/17/2023 through 3/8/2023, did not include documentation of a Chaplain visit plan or interventions. The patient’s date of death was 3/11/2023. Clinical Record 14: The patient elected the hospice benefit on 11/23/2022. The Plan of Care Orders from 11/30/2022 through 2/8/2022 stated the Chaplain frequency of visits was monthly. Documentation in each visit performed 11/23/2022, 12/23/2022, and 1/23/2023 stated, "Purpose of Visit: To provide a ministry of presence. To encourage spiritual well-being of patient and family.” The Problem List identified in the Interdisciplinary Team updates from 11/30/2022 through 2/8/2023, did not include documentation of Chaplain visit plan or interventions. In an interview and discussion of the agency’s current Interdisciplinary Group documentation process on 5/25/2023, the Director of Clinical Services and the Executive Director confirmed that the IDG Group Meeting updates did not include changes that have taken place in the assessments over the previous two weeks.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including interventions to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the patient's plan of included services necessary to manage the patient's constipation. Clinical Record 4: The patient elected the hospice benefit on 3/21/2023. On the RN Initial Assessment dated 3/21/2023, the nurse documented the patient had a fecal impaction that was causing the patient pain. Additionally, under the "Digestive" heading, the nurse documented the patient had chronic constipation and used Colace. Under "Nutrition and Fluid Intake Screening," the nurse documented "difficulty with constipation." The nurse received a physician order dated 3/21/2023 for a Mineral Oil Enema for fecal impaction. The order stated, "...if not effective, please manually disimpact." In the Plan of Care Order dated 3/24/2023, the only problems identified were "Pain" and "Emotional." There was no documented evidence in the clinical record that constipation was added to the list of problems for this patient or that interventions and goals related to the management of constipation were added to the patient's plan of care. In an interview on 5/24/2023, the Director of Clinical Services confirmed the patient's constipation and fecal impaction should have been identified in the list of problems for the patient and interventions and outcomes to ensure the management of this assessment finding should have been included in the plan of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) clinical record reviewed revealed that the agency did not ensure that the patient's clinical records contained written plans of care with accurate statements of the scope and frequency of services necessary to meet the patients' needs. Clinical Record 1: The patient elected the hospice benefit on 3/23/2023. The Initial Plan of Care Order dated 4/6/2023 and the subsequent updated Plan of Care Order dated 4/20/2023 did not include a visit frequency for Chaplain visits. The Chaplain made a visit to the patient on 4/23/2023 without an order. During an interview with the Director of Clinical Services on 5/24/2023 and 5/25/2023, there was no additional information or documentation provided, and it was confirmed that these records did include the correct scope and frequency of visits.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and, is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by document review, Quality Assessment and Performance Improvement (QAPI) documents, and interviews with the Executive Director and Clinical Director, which revealed issues with the organization's QAPI program in the following areas: Failed to maintain a coordinated, agency-wide program for infection surveillance and the identification, prevention, control and investigation of infectious and communicable diseases [HQPI.6.I/L580]; Failed to measure success and track performance to ensure improvements were sustained after implementing performance improvement projects [HQPI.8.I/L570]; Failed to use patient care and other relevant data in the design of the agency QAPI program [HQPI.5.I/L563]; and Failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance to enable the hospice to assess processes of care, hospice services, and operations [HQPI.4.I/L562]. The cumulative effect of these deficiencies could impact the organization's ability to assess the care and services provided by hospice and ensure the provision of high-quality care and services.

It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse events. This standard was not met as evidenced by document review and interview. The hospice did not ensure that quality indicators of performance were measured, analyzed, and tracked to enable assessment of processes of care, hospice services, operations, and adverse events. Review of the QAPI Meeting Minutes dated 3/15/2023, 11/9/2022, and 4/13/2022, revealed the agency did not ensure a comprehensive, high-level overview of data collection or analysis that could adversely impact patient/family care and hospice operations. Particularly as it related to the COVID Public Health Emergency, there was no reporting on infection control, COVID infection tracking, or medical supplies as it related to personal protective equipment during the PHE, staffing, or adverse events. In the QAPI Meeting minutes, there was no information gathered from clinical record audits that were performed. Agency Policy "Quality Assessment/Performance Improvement (QAPI)" 14.7.1 with the effective date of March 2013, stated in part, "Patient focused quality assessment and improvement activities include: ... Comprehensive assessment and care planning (record review), Patient teaching and levels of understanding (record review) ...Clinical record reviews: compliance with plans of care, appropriateness of care and services provided ... Safety issues (incident reporting), problem identification and resolution, evaluation of systems designed to support clinical operations ...Use of program evaluation findings based on measurable objectives, patient outcomes ...Monitoring and measuring the satisfaction levels of patients/caregivers, both active and discharged, is conducted at least one time each year - Findings are tracked, trended, and analyzed for the purposes of program planning and developing strategies to improve care and service delivery." Agency Policy "QAPI Program" 10.1,1 with the revised date of February 2023, stated under the heading "Performance Expectations," "For each process identified to be improved, mechanisms to identify levels, patterns, or trends in that process that will trigger further evaluation ...will be identified. Performance expectations may include, but are not limited to thresholds, setting upper and lower control limits, percentages, ratios, setting performance goals for further evaluation, identification of patterns/trends...The QAPI Committee ...will analyze the data collected to pursue opportunities for improvement and identify important problems...A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee...Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement." Topics covered during the QAPI Meetings and reflected in the QAPI Meeting Minutes were limited to: 4/13/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: QAPI Continuous Improvement, QAPI Skilled Professionals, Signed Verbal Orders, Hand Hygiene, DC Summaries, Individual Emergency Plans," and "Review CASPER Reports." This was the extent of the meeting minutes. No compliance scores, goals, or progress information was presented. 11/9/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: Visit Schedules in Patient Home Folders, Out of Parameter VS Reporting, Infection Control Teaching." "Review CASPER Reports." "Reviewed and decided to keep current Emergency Plan in place." This was the extent of the meeting minutes. No data, compliance scores, goals, or progress information was presented. 3/15/2023: "Reviewed all current performance improvement plans" (no measurement data included in minutes). "Added new performance improvement Plans: Individual Emergency Plans and Orders Greater than 30 Days to Get Signed." "Reviewed and brainstormed (no discussion topics included) any lessons learned from the January Freeze." With these meeting minutes, there was no QAPI report or quantitative data presented, no tracking of measurable outcomes of quality, no adverse events, and no review of any clinical record scores, findings, or trends represented. In an interview with the Director of Clinical Services and the Executive Director (ED) on 5/25/2023, these findings were discussed and confirmed. The Director of Clinical Services and ED confirmed that information presented in the QAPI Meeting Minutes did not include a review, analysis or tracking of measurable data and analysis required by the Standards and regulations. No additional documentation was presented prior to the conclusion of the Site Visit. In a review of the QAPI Meeting Minutes from dated 3/15/2023, 11/9/2022, and 4/13/2022, it was revealed that the agency did not ensure a comprehensive, high-level overview of data collection or analysis that could adversely impact patient/family care and hospice operations. Particularly as it related to the COVID Public Health Emergency, there was no reporting on infection control, COVID infection tracking, or medical supplies as it related to personal protective equipment during the PHE, staffing, or adverse events. In the QAPI Meeting minutes, there was no information gathered from clinical record audits performed. The agency's policy "Quality Assessment/Performance Improvement (QAPI)" 14.7.1 with the effective date of March 2013, reads that "Patient focused quality assessment and improvement activities include: ... Comprehensive assessment and care planning (record review), Patient teaching and levels of understanding (record review) ...Clinical record reviews: compliance with plans of care, appropriateness of care and services provided ... Safety issues (incident reporting), Problem identification and resolution, Evaluation of systems designed to support clinical operations ...Use of program evaluation findings based on measurable objectives, patient outcomes ...Monitoring and measuring the satisfaction levels of patients/caregivers, both active and discharged, is conducted at least one time each year - Findings are tracked, trended, and analyzed for the purposes of program planning and developing strategies to improve care and service delivery." The agency's policy "QAPI Program" 10.1,1 with the revised date of February 2023, reads under the heading of "Performance Expectations," "For each process identified to be improved, mechanisms to identify levels, patterns, or trends in that process that will trigger further evaluation ...will be identified. Performance expectations may include, but are not limited to thresholds, setting upper and lower control limits, percentages, ratios, setting performance goals for further evaluation, identification of patterns/trends...The QAPI Committee ...will analyze the data collected to pursue opportunities for improvement and identify important problems...A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee...Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement." Topics covered during the QAPI Meetings and reflected in the QAPI Meeting Minutes were limited to: 4/13/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: QAPI Continuous Improvement, QAPI Skilled Professionals, Signed Verbal Orders, Hand Hygiene, DC Summaries, Individual Emergency Plans," and "Review CASPER Reports." This was the extent of the meeting minutes. No compliance scores, goals, or progress information was presented. 11/9/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: Visit Schedules in Patient Home Folders, Out of Parameter VS Reporting, Infection Control Teaching." "Review CASPER Reports." "Reviewed and decided to keep current Emergency Plan in place." This was the extent of the meeting minutes. No data, compliance scores, goals, or progress information was presented. 3/15/2023: "Reviewed all current performance improvement plans" (no measurement data included in minutes). "Added new performance improvement Plans: Individual Emergency Plans and Orders Greater than 30 Days to Get Signed." "Reviewed and brainstormed (no discussion topics included) any lessons learned from the January Freeze." With these meeting minutes, there was no QAPI report or quantitative data presented, no tracking of measurable outcomes of quality, and no review of any clinical record scores, findings, or trends represented. In an interview with the Director of Clinical Services and the Executive Director on 5/25/2023, these findings were discussed. No further documentation was produced prior to the Exit Conference. The Executive Director did actively pursue questions to understand ways in which to reach this requirement, and both confirmed that what was presented in the QAPI Meeting Minutes did not have the quantitative, measurable data and analysis required by the Standards and regulations.

It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the design of the QAPI program. This standard was not met as evidenced by document review and interview. Review of the agency Quality Assessment and Performance Improvement (QAPI) documentation revealed the organization did not use patient care and other relevant data in the design of the agency QAPI program. Agency Policy "QAPI Program" 10.1,1 with the revised date of February 2023, stated in part under the heading of "Performance Expectations," "For each process identified to be improved, mechanisms to identify levels, patterns, or trends in that process that will trigger further evaluation ...will be identified. Performance expectations may include, but are not limited to thresholds, setting upper and lower control limits, percentages, ratios, setting performance goals for further evaluation, identification of patterns/trends...The QAPI Committee ...will analyze the data collected to pursue opportunities for improvement and identify important problems...A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee...Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement." Review of QAPI Committee Meeting Minutes for 4/13/2022, 11/9/2022 and 3/15/2023 did not include documented evidence that patient care or other relevant data was identified and used in the design of the QAPI program. The QAPI Meeting Minutes provided a general overview of topics reviewed during the meetings. There was no documented evidence in the minutes that patient care and other quantitative, measurable quality data was collected, aggregated and analyzed or used in quality assessment and improvement activities. No compliance scores, goals for improvement, or progress related to performance improvement activities were included in the QAPI Meeting Minutes. Topics covered during the QAPI Meetings and reflected in the QAPI Meeting Minutes were limited to: 4/13/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: QAPI Continuous Improvement, QAPI Skilled Professionals, Signed Verbal Orders, Hand Hygiene, DC Summaries, Individual Emergency Plans," and "Review CASPER Reports." This was the extent of the meeting minutes. No compliance scores, goals, or progress information was presented. 11/9/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: Visit Schedules in Patient Home Folders, Out of Parameter VS Reporting, Infection Control Teaching." "Review CASPER Reports." "Reviewed and decided to keep current Emergency Plan in place." This was the extent of the information presented in the information presented in the meeting minutes. No data, compliance scores, goals, or progress information was presented. 3/15/2023: "Reviewed all current performance improvement plans" (no measurement data included in minutes). "Added new performance improvement Plans: Individual Emergency Plans and Orders Greater than 30 Days to Get Signed." "Reviewed and brainstormed (no discussion topics included) any lessons learned from the January Freeze." The meeting minutes were one-page documents with these line items only. In an interview on 5/25/2023, the findings were discussed with the Director of Clinical Services and the Executive Director who confirmed that the QAPI Meeting Minutes did not include quantitative, measurable data and analysis as required by the Standards and regulations. No further documentation was produced prior to the Exit Conference. In a review of the QAPI Meeting Minutes from dated 3/15/2023, 11/9/2022, and 4/13/2022, it was revealed that the agency did not ensure a comprehensive, high-level overview of scores, tracking, trending, or analysis presented in a QAPI report. The only documentation available was the meeting minutes with the topics listed below without any supporting scores or data collected and presented. The agency's policy "QAPI Program" 10.1,1 with the revised date of February 2023, reads under the heading of "Performance Expectations," "For each process identified to be improved, mechanisms to identify levels, patterns, or trends in that process that will trigger further evaluation ...will be identified. Performance expectations may include, but are not limited to thresholds, setting upper and lower control limits, percentages, ratios, setting performance goals for further evaluation, identification of patterns/trends...The QAPI Committee ...will analyze the data collected to pursue opportunities for improvement and identify important problems...A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee...Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement." Topics covered during the QAPI Meetings and reflected in the QAPI Meeting Minutes were limited to: 4/13/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: QAPI Continuous Improvement, QAPI Skilled Professionals, Signed Verbal Orders, Hand Hygiene, DC Summaries, Individual Emergency Plans," and "Review CASPER Reports." This was the extent of the meeting minutes. No compliance scores, goals, or progress information was presented. 11/9/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: Visit Schedules in Patient Home Folders, Out of Parameter VS Reporting, Infection Control Teaching." "Review CASPER Reports." "Reviewed and decided to keep current Emergency Plan in place." This was the extent of the meeting minutes. No data, compliance scores, goals, or progress information was presented. 3/15/2023: "Reviewed all current performance improvement plans" (no measurement data included in minutes). "Added new performance improvement Plans: Individual Emergency Plans and Orders Greater than 30 Days to Get Signed." "Reviewed and brainstormed (no discussion topics included) any lessons learned from the January Freeze." The meeting minutes were one-page documents with these line items only. In an interview with the Director of Clinical Services and the Executive Director on 5/25/2023, these findings were discussed. No further documentation was produced prior to the Exit Conference. The Executive Director did actively pursue questions to understand ways in which to reach this requirement, and both confirmed that what was presented in the QAPI Meeting Minutes did not have the quantitative, measurable data and analysis required by the Standards and regulations.

It is required that the hospice takes action to improve performance, assesses the success of the action after implementing it and tracks ongoing results to ensure improvement is sustained. This standard was not met as evidenced by document review and interview. Review of agency documentation related to performance improvement projects revealed there was no documented evidence that after completing performance improvement projects, the agency continued to track and monitor ongoing results to ensure improvements were sustained. Agency Policy "QAPI Program" 10.1, with the revised date of February 2023, stated in part under the heading of "Performance Expectations," "For each process identified to be improved, mechanisms to identify levels, patterns, or trends in that process that will trigger further evaluation...will be identified. Performance expectations may include, but are not limited to thresholds, setting upper and lower control limits, percentages, ratios, setting performance goals for further evaluation, identification of patterns/trends...The QAPI Committee ...will analyze the data collected to pursue opportunities for improvement and identify important problems...A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee...Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement." In the same policy, under the heading of "Achieved and Sustained Improvement," the policy stated, "The Administrator/Director is responsible for taking appropriate action. Aggregate measures of performance for each process will be compared to pre-established performance expectations to determine if additional evaluation is required. If the performance expectation is not met, the findings will be evaluated by the Administrator/Director to determine the systematic approach for making improvement. The systematic approach will include: Identification of potential improvement, Test of action for change, Analyzing data from the test to determine if change improved performance, Implement improvement strategy system wide." Further, the policy stated in part, "Actions to improve systems may include ... forms: design/redesign...altering structures or processes... policy/procedure review...All improved processes will continue to be analyzed for a specified time to determine if test piloted action has resulted in sustained improvement...Hospice will document... the measurable progress achieved...” Upon review of the agency's QAPI Performance Improvement Projects (PIPs), there was documented evidence of the development of two current performance improvement plans (PIPs) to address identified problems. One PIP was initiated on 5/17/2023 to address a decline in volunteer services related to the COVID-19 Public Health Emergency. The other PIP was developed to address problems identified with the timely completion of aide supervisory visits. Previous PIPs were implemented and completed as follows: Bag Technique initiated 9/3/2020 and completed 4/8/2021; Physician Orders/Using PRN Visits Incorrectly/Incorrect Documentation of Missed Visits initiated 9/18/2020 and completed 12/4/2020; 9/3/2020 Written Plan of Care (Use of PRN Visits) initiated 9/3/2020 and completed 11/3/2020; 9/2/2020 Written Aide Care Plans (Following the Aide Care Plan) initiated 9/2/2020 and completed 11/3/2020; and Written Aide Care Plans (Use of PRN Visits) initiated 9/2/2020 and completed 11/3/2020. There was no documented evidence that the agency continued to assess the success of these PIPs after implementing and completing the PIPs to ensure that improvement was sustained. Ongoing results were not tracked over time as evidenced by no supporting documentation of ongoing monitoring after the conclusion of the PIP. In an interview with the Executive Director and the Director of Clinical Services on 5/24/2023 and 5/25/2023, it was confirmed that there were 2 PIPs currently in place and that there was no ongoing monitoring for the previous PIPs that had been closed, to ensure improvements were sustained. No further documentation was presented by the end of the Site Visit. Upon review of the agency's QAPI Performance Improvement Projects (PIPs), it was revealed that the agency did not continue to assess the success of the PIPs after implementing the PIP and completing the PIP. Ongoing results were not tracked over time, as evidenced by no supporting documentation of ongoing monitoring after the conclusion of the PIP. Additionally, upon reviewing the previous Site Visit findings from August 2020, some of the PIPs developed to address those required actions were found as preliminary required actions during this Site Visit. There were two current hospice PIPs at the time of the Site Visit. One was initiated on 5/17/2023 for the Volunteer Program as “Due to Public Health Emergency (PHE), our volunteer program declined …volunteer coordinator hours increased from 30 hrs/week to 40 hrs/week." The implementation of the corrective action plan was set to begin on 5/22/2023. The second PIP was dated from 9/3/2020 for Aide Supervision with a projected completion date of 11/3/2020; however, there was a gap in the documentation from 2021 to 5/11/2023 when the PIP included the action, "New DON and Administrative Assistant will monitor ...for Aide Supervisory visits by-weekly." Aide Supervision was part of the agency's Plan of Correction after the August 2020 Site Visit. During this Site Visit, AIde Supervision was found again not to be compliant. The only other hospice PIPS were: 9/10/202: Performance Improvement Plan Projects – completed 11/8/2021, 9/3/2020: Bag Technique – completed 4/8/2021, 9/18/2020: Physician Orders/Using PRN Visits Incorrectly/Incorrect Documentation of Missed Visits -completed 12/4/2020, 9/3/2020 – Written Plan of Care (Use of PRN Visits) – completed 11/3/2020, 9/2/2020 – Written Aide Care Plans (Following the Aide Care Plan) – completed 11/3/2020, and lastly, 9/2/2020 – Written Aide Care Plans (Use of PRN Visits) – completed 11/3/2020. The agency's policy "QAPI Program" 10.1, with the revised date of February 2023, reads under the heading of "Performance Expectations," "For each process identified to be improved, mechanisms to identify levels, patterns, or trends in that process that will trigger further evaluation ...will be identified. Performance expectations may include, but are not limited to thresholds, setting upper and lower control limits, percentages, ratios, setting performance goals for further evaluation, identification of patterns/trends...The QAPI Committee ...will analyze the data collected to pursue opportunities for improvement and identify important problems...A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee...Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement." In the same policy, under the heading of "Achieved and Sustained Improvement," the policy reads as follows, "The Administrator/Director is responsible for taking appropriate action. Aggregate measures of performance for each process will be compared to pre-established performance expectations to determine if additional evaluation is required. If the performance expectation is not met, the findings will be evaluated by the Adminstrator/Director to determine the systematic approach for making improvement. The systematic approach will include: Identification of potential improvement, Test of action for change, Analyzing data from the test to determine if change improved performance, Implement improvement strategy system wide." Further, it reads, "Actions to improve systems may include ... forms: design/redesign ...altering structures or processes ... policy/procedure review...All improved processes will continue to be analyzed for a specified tie to determine if test piloted action has resulted in sustained improvement...Hospice will document ... the measurable progress achieved..." In an interview with the Executive Director and the Director of Clinical Services on 5/24/2023 and 5/25/2023, it was confirmed that these were the only hospice PIPs in place and that there was no ongoing monitoring in place for the previous PIPs that had been closed. No further documentation was presented by the end of the Site Visit.

It is required that hospice performance improvement (PI) activities include the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. This standard was not met as evidenced by document review and interview. There was no documented evidence that the agency maintained a coordinated, agency-wide program for infection surveillance, the identification, prevention, control and investigation of infectious and communicable diseases. Agency Policy, "Infection Control Committee," 5.13.1 with the revised date of June 2019, stated, "The Hospice infection Control Committee is comprised of the Director, Nursing Supervisor, appropriate staff representation (social worker, hospice aide), Medical Director. The responsibilities of the committee include: Analyzing data from the infection control surveillance system and taking appropriate actions developing, reviewing, and revising infection control education programs for staff, and Assuring implementation of OSHA standards for bloodborne pathogens and tuberculosis control." Agency Policy, "Infection Control Surveillance System: Prioritized Risks Defined," 5.1.1 with the revised date of June 2019, stated, "At least quarterly, the Director and Infection Control and QAPI Committees will review and assess the infection control logs. Data will be aggregated and analyzed on the 'Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees' form. Problems and/or undesirable trends in infections will be identified, including potential significant Hospice acquired and/or community-acquired infections. If such problems or undesirable trends are identified, the infection control and QAPI committees will identify any common factors that could have led to the transmission of infections. The committees will make recommendations for and implement improvement activities." A review of the hospice agency's QAPI Meeting Minutes dated 3/15/2023, 11/9/2022, and 4/13/2022, revealed there was no documentation that the agency presented any employee or patient infection-related information during the meetings. The meeting minutes for each date included only the topics covered without compliance scores, audits, or specific data. The QAPI Meeting Minutes stated, “Reviewed all current performance improvement plans,” but the minutes did not include the specific focus of each performance improvement plan or scores/data related to the plans. There were no infection logs for 2023, 2022, or 2021 in the Hospice QAPI Binder. Employee and patient infections were not recorded on the agency "Quarterly Review of Quality Indicators and Adverse Events Tool.” During an interview on 5/25/2023, the Executive Director and the Director of Clinical Services confirmed that the agency did not have any further documentation regarding patient or employee infections and that no information related to monitoring, tracking, trending, or analysis of infections was presented in the QAPI Committee Meetings or included in the QAPI Meeting Minutes. In a review of the hospice agency's QAPI Meeting Minutes dated 3/15/2023, 11/9/2022, and 4/13/2022, there was no documentation that the agency presented any infection-related information. The meeting minutes for each date included only the topic covered without compliance scores, audits, or background data and consisted of for 3/15/2023 - "Reviewed all current performance improvement plans (no topic or scores), Added new performance improvement plans: individual emergency plans and orders greater than 30 days to get signed (no background data, scores, audits, etc.), Review CASPER reports (no data or scores mentioned or highlighted), 11/9/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: Visit Schedules in Patient Home Folders, Out of Parameter VS Reporting, Infection Control Teaching (no compliance or plan to continue monitoring)." "Review CASPER Reports (no data or scores mentioned)." "Reviewed and decided to keep current Emergency Plan in place." 4/13/2022: "Reviewed all current performance improvement plans" (no measurement data included in minutes), "Completed Performance improvement Plans: QAPI Continuous Improvement, QAPI Skilled Professionals, Signed Verbal Orders, Hand Hygiene, DC Summaries, Individual Emergency Plans," and "Review CASPER Reports." This was the extent of the meeting minutes. No compliance scores, goals, or progress information was presented. In the Hospice QAPI Binder, there were no infection logs for 2023, 2022, or 2021. There was a "Quarterly Review of Quality Indicators and Adverse Events Tool," where the number of each of the following was logged: patient injuries/incidents, other patient incidents, employee incidents, accidents, staff administered medication errors, other medication errors, adverse drug reactions, drug diversion of hospice-provided medications, patient falls with injury requiring medical intervention, and worker compensation claims. There was not a line item on the tool for either patient or employee infections. And the tool contained a blank to enter the number of each event but no background data. The agency's policy, "Infection Control Committee," 5.13.1 with the revised date of June 2019, reads, "The Hospice infection control committee is comprised of the Director, Nursing Supervisor, appropriate staff representation (social worker, hospice aide), Medical Director. The responsibilities of the committee include: Analyzing data from the infection control surveillance system and taking appropriate actions developing, reviewing, and revising infection control education programs for staff, and Assuring implementation of OSHA standards for bloodborne pathogens and tuberculosis control." The agency policy, "Infection Control Surveillance System: Prioritized Risks Defined," 5.1.1 with the revised date of June 2019, reads, "At least quarterly, the Director and infection control and QAPI committees will review and assess the infection control logs. Data will be aggregated and analyzed on the 'Infection Control Quartley Data Aggregation and Analysis: Patients and Employees' form. Problems and/or undesirable trends in infections will be identified, including potential significant Hospice acquired and/or community-acquired infections. If such problems or undesirable trends are identified, the infection control and QAPI committees will identify any common factors that could have led to the transmission of infections. The committees will make recommendations for and implement improvement activities." During an interview with the Executive Director and the Director of Clinical Services on 5/25/2023, it was confirmed that the agency did not have any further documentation regarding patient or employee infections, that no infection information monitoring, tracking, trending, or analysis was presented in the QAPI Committee Meetings or QAPI Meeting Minutes. There were no infection logs produced.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care, including conducting ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that professional standards of practice were followed in assessing a patient with an acute change of condition. Agency Policy, "Reassessment/Update to the Comprehensive Assessment" 9.8.1 with the effective revision date of February 2021, stated, " Each patient will be assessed when a significant change in condition status...occurs." Agency Policy, "IDG Care Planning Process" 9...12.2 with the effective revision date of February 2022 stated, "A registered nurse that is a member of the IDG is designated to provide coordination of care, coordinating and implementing the plan of care and to ensure continuous assessment of each patient's and family's needs ...The RN ensures that the plan of care is ...updated .... communicating with the IDG any changes in the delivery of services from the established plan of care ...working with other members of the IDG to ease inclusion of additional services when indicated ...developing and revising patient care goals/objectives in coordination with other members of the IDG, monitoring for successful implementation of the plan of care." Texas Board of Nursing Position Statement 15.27, The Licensed Vocational Nurse (LVN) Scope of Practice, stated in part, "The LVN cannot perform independent assessments as the LVN has a directed scope of practice under supervision. The LVN participates in the nursing process by appraising the individual patient’s status or situation at hand. This represents a focused assessment and may be considered a component of a more comprehensive assessment performed by a RN or another appropriate clinical supervisor." Clinical Record 6: The patient elected the hospice benefit on 7/27/2022. In the LVN Skilled Nursing Visit note dated 4/19/2023, the nurse documented, "Pt wheezing in lungs throughout. O2 sat on room air at 80%. O2 applied at 2.5L NC increased O2 sat to 93%...decreased appetite, refused to eat or drink since 4/18/2023...not alert or verbal during visit." The documentation stated the patient was lethargic with decreased skin turgor and "pt was lying in bed resting with bile vomit all over her clothes and sheets." These findings were new compared to the 4/11/2023 RN Skilled Nursing Visit note documentation which stated the patient had an oxygen saturation of 93% on room air with even, unlabored respirations and no evidence of respiratory distress. The RN documented the patient was consuming 75-100% of meals and was able to ambulate independently with a rolling walker. The LVN did not report the acute change in the patient's status to the RN. New orders were received from the physician on 4/19/2023 for Prednisone 10mg dose pack and Azithromycin 500mg daily. The RN did not make a follow-up visit to perform a comprehensive assessment of the patient's status until 4/27/2023, which was eight days after the LVN visit. In an interview on 5/24/2023, after reviewing the visit note documentation and findings, the Director of Clinical Services confirmed that an RN should have followed up with the patient sooner than eight days after the LVN visit.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 4 of 13 (31%) clinical records reviewed of patients who received aide services revealed the agency did not ensure that the aide plan of care included specific care instructions for the assigned patients. Clinical Record 1: The patient elected the hospice benefit on 3/23/2023. The admitting diagnosis for the patient was neurocognitive disorder secondary to Parkinson's disease, and the patient resided in a locked Memory Care Unit within an assisted living facility. The Aide Care Plan dated 3/23/2023 included the following interventions "as needed" and not assigned to a specific frequency or day and included multiple choices for the bath/shower task: complete bed bath, partial bath/shower, complete shower, pericare, incontinent care, assist with bedpan, shave, shampoo hair, comb hair, skin care, assist to dress, and change linen. Due to the decreased cognitive function of the patient, the patient was unable to make a determination as to what interventions were required for care. The patient resided in a facility and not in a home where the patient's family member could participate in the determination of care needs. Clinical Record 3: The patient elected the hospice benefit on 12/21/2022. The admitting diagnosis for the patient was Alzheimer's and the patient resided in a locked Memory Care Unit within an assisted living facility (ALF). The Aide Care Plan dated 4/20/2023 included interventions "as needed" and not assigned to a specific frequency or day and included multiple choices of bath/shower: complete bed bath, partial bath/shower, complete shower, and shampoo hair. Due to the decreased cognitive function of the patient, the patient was unable to make a determination as to what interventions were required for care. The patient resided in a facility and not in a home where the patient's family member could participate in the determination of care needs. Clinical Record 4: The patient elected the hospice benefit on 3/21/2023. The admitting diagnosis for the patient was senile degeneration of the brain and the patient resided in a locked Memory Care Unit within an assisted living facility (ALF). The Aide Care Plan dated 3/21/2023 included the following interventions "as needed" and not assigned to a specific frequency or day and included multiple choices of bath/shower: complete bed bath, partial bath/shower, complete shower, pericare, assist with bedpan, incontinent care, assist with bedside commode and comb hair. Additionally, the task of shampooing hair was assigned biweekly and not assigned to specific aide visit days. Due to the decreased cognitive function of the patient, the patient was unable to make a determination as to what interventions were required for care. The patient resided in a facility and not in a home where the patient's family member could participate in the determination of care needs. Clinical Record 11: The patient elected the hospice benefit on 2/16/2023. The admitting diagnosis for the patient was senile degeneration of the brain and the patient resided in a locked Memory Care Unit within an assisted living facility. The Aide Care Plan dated 2/16/2023 included for the patient to have a complete shower every visit but also included in the interventions for a complete bed bath to be performed as needed ("PRN"). Due to the decreased cognitive function of the patient, the patient was unable to make a determination as to what interventions were required for care. The patient resided in a facility and not in a home where the patient's family member could participate in the determination of care needs. In an interview with the Director of Clinical Services on 5/23/2023 and 5/24/2023, it was confirmed that the care plans in records 1, 3, 4, and 11 created by the RN included multiple bath options for the patients and also other care interventions did not specify how often the aide should perform assigned tasks each week with the patients.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. 4 of 13 (31%) clinical records reviewed of patients who received aide services revealed the agency did not ensure that the aide services provided were consistent with the services ordered by the Interdisciplinary Group. Clinical Record 2: The patient elected the hospice benefit on 8/19/2021. The Plan of Care Order updates/Interdisciplinary Group Meetings dated 4/6/2023, 4/20/2023, 5/4/2023, and 5/18/2023 stated the aide visit frequency was five to thirteen times per week. There was not documented evidence in the clinical record that aide visits were provided at the ordered frequency from 4/11/2023 to 5/18/2023. Clinical Record 4: The patient elected the hospice benefit on 3/21/2023. In the initial Plan of Care Order dated 3/22/2023 and the subsequent Plan of Care Order update/Interdisciplinary Group Meeting on 3/24/2023, aide services were ordered five times a week. In the documented Aide Care Visits for 3/22/2023, 3/23/2023, 3/24/2023, 3/27/2023, 3/28/2023, 3/29/2023, 3/30/2023, and 3/31/2023, no aide care plan Instruction/Interventions were documented as having been completed, and the "Aide Comments," section was blank with no indication the nurse was notified of any problems. There was no documentation of the aide services provided during the visits. Clinical Record 7: The patient elected the hospice benefit on 10/26/2022. Per the Plan of Care Order/Interdisciplinary Group (IDG) update dated 4/20/2023, the IDG ordered aide visits five times a week. For the week of 5/1/2023 to 5/5/2023, the clinical record included documentation of aide visits on 5/2/2023 and 5/3/2023 and there was one documented missed aide visit on 5/4/2023. Aide services were not provided at the ordered frequency of five times per week. Clinical Record 8: The patient elected the hospice benefit on 7/18/2022. Per the Plan of Care Order updates/IDG updates dated 4/5/2023, 4/19/2023, 5/3/2023, and 5/18/2023, the aide visit frequency was three times a week. For the weeks 4/2/2023 to 4/8/2023, 4/9/2023 to 4/15/2023, 4/23/2023 to 4/29/2023, 4/30/2023 to 5/6/2023, and 5/7/2023 to 5/13/2023, the documentation in the clinical record indicated two aide visits were provided each week. Aide services were not provided at the ordered visit frequency of three times per week. In interviews on 5/24/2023 and 5/25/2023, the Director of Clinical Services confirmed there was no additional documentation of aide visits existing outside of the clinical records and aide services were not provided at the ordered visit frequencies.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary and the patient’s record if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed of patients who revoked the hospice benefit revealed the agency did not ensure that the discharge summary was sent to the hospital when the patient revoked the hospice benefit and transferred to the hospital for treatment. Clinical Record 14: The patient elected the hospice benefit on 11/23/2022. On 2/14/2023 the nurse completed the "Discharge - Live" document that included the staff member's time in and time out, discharge order date (only signed by RN), patient status: "discharge to home or self-care", reason for discharge: "discharged - patient no longer terminally ill, state": and in the comments: "Patient had a fall and with a fx hip was admitted to the hospital for surgery patient revoked the hospice benefit." The "Discharge - Live" document did not include a summary of the patient's care while on hospice and did not include documentation of the patient's medications, treatments/symptom management or orders. The clinical record did not include documented evidence that the patient's discharge summary or any of the patient's clinical record was sent to the facility where the patient was transferred for treatment of the hip fracture. In an interview with the Director of Clinical Services and the Executive Director, it was confirmed that the "Discharge - Live" visit document was the only Discharge Summary completed and there was no documentation in the clinical record that this form was sent to the hospital where the patient was admitted for care.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record if requested. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records reviewed of patients who revoked the hospice benefit revealed the agency did not ensure that a copy of the discharge summary was sent to the patient's attending physician. Clinical Record 11: The patient elected the hospice benefit on 2/16/2023. On 3/30/2023, the patient's family signed a Revocation form to end the patient's hospice care. On 3/30/2023, the nurse completed the "Discharge - Live" document that included the staff member's time in and time out, discharge order date (only signed by RN), patient status: discharge to home or self-care, reason for discharge: discharged - patient no longer terminally ill, state: stable, comments: "Patient is dc'd his family signed for the patient to be revoked from hospice." The clinical record did not include documented evidence that the discharge summary or any clinical record documentation was sent to the patient's attending physician. Clinical Record 14: The patient elected the hospice benefit on 11/23/2022. On 2/14/2023 the nurse completed "Discharge - Live" document that included the staff member's time in and time out, discharge order date (only signed by RN), patient status: discharge to home or self-care, reason for discharge: discharged - patient no longer terminally ill, state: ppr, comments: "Patient had a fall and with a fx hip was admitted to the hospital for surgery patient revoked the hospice benefit." The "Discharge - Live" document did not include a summary of the patient's care while on hospice, and no medications, treatments/symptom management, or orders. The clinical record did not include documented evidence that the patient's discharge summary or any clinical record documentation was sent to the patient's attending physician. In an interview with the Director of Clinical Services and the Executive Director, it was confirmed that there was no documentation in the clinical records that the patients' discharge summaries were sent to the attending physicians when the patients revoked the hospice benefit.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records reviewed in which live discharges from hospice occurred revealed the discharge summary did not include a summary of the patient's hospice stay, medications or treatments, care plans, or physician orders. Clinical Record 11: The patient elected the hospice benefit on 2/16/2023. On 3/30/2023, the patient's family signed a Revocation form to end the patient's hospice care. On 3/30/2023, the nurse completed the "Discharge - Live" document that included the staff member's time in and time out, discharge order date (only signed by RN), patient status: "discharge to home or self-care", reason for discharge: "discharged - patient no longer terminally ill", state: "stable", comments: "Patient is dc'd his family signed for the patient to be revoked from hospice." The "Discharge - Live" document did not include any summary of the patient's care while on hospice and no medications, treatments/symptom management, or orders. Clinical Record 14: The patient elected the hospice benefit on 11/23/2022. On 2/14/2023, the nurse completed the "Discharge - Live" document that included the staff member's time in and time out, discharge order date (only signed by RN), patient status: "discharge to home or self-care", reason for discharge: "discharged - patient no longer terminally ill, state," comments: "Patient had a fall and with a fx hip was admitted to the hospital for surgery patient revoked the hospice benefit." The "Discharge - Live" document did not include any summary of the patient's care while on hospice and no medications, treatments/symptom management, or orders. In an interview on 5/25/2023, the Director of Clinical Services and the Executive Director on 5/25/2023, confirmed that the "Discharge - Live" document was the only discharge summary completed and that the required summary of care, medications, treatments, care plans, or physician orders was not included on any other discharge document.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. 1 of 6 (17%) contracts reviewed revealed the agency did not ensure that the contract included the requirement that a criminal background check must be performed for any contract staff with access to patients or clinical records. Contract 4: A review of the contract for transportation services with the effective date of 2/26/2018 revealed the contract did not include a provision that any transport staff with direct patient contact or access to patient records was required to have a criminal background check. In an interview on 5/25/2023, the Executive Director/Administrator confirmed the contract did not include the requirement for transport staff background checks. He was reaching out to the company to update this requirement in the contract.