Every finding on record at Vital Hospice Care, Inc.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) records reviewed, in which aide services were accepted, revealed the agency did not ensure the RN provided the specific guidance required to perform assigned patient care tasks. Clinical Record 3: The patient elected hospice benefit on 03/01/2024 with a diagnosis of Alzheimer's disease. The registered nurse assessment dated 03/01/2024 documented the patient had a wound with a dressing intact to the right heel. The aide care plan, effective from 03/01/2024 to current, included the relevant task of providing a "complete bed bath" at each visit. The care plan did not alert the aide that the patient had a wound dressing and did not include guidance to inform the RN if the dressing was soiled or dislodged. During an interview, conducted on 03/05/2024, the Director of Client Services (DCS) confirmed that the patient still had the wound dressing and reported aide care plan should have included information on the wound dressing and stated, "I have already updated it."

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: The primary terminal condition; Related diagnosis(es), if any; Current subjective and objective medical findings; Current medication and treatment orders; Information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) records reviewed revealed the agency did not ensure the physician narrative, on the certification of terminal illness, contained evidence the physician considered the patient's scope of illness when making the determination. Clinical Record 1: The "Hospice of Certification of Terminal Illness" for the patients' initial benefit period 2/16/2024 to 5/15/2024 contained the following physician narrative, "Patient has advanced heart failure and atherosclerosis. He has a life expectancy of less than 6 months." The form was signed by the Medical Director on 2/27/2024. Per the initial nursing assessment dated 2/16/24, the RN documented, "the PCG (primary care giver) noticed the patient is having difficulty swallowing and would even forget how to swallow. Recent falls secondary to syncopal episodes. Recently admitted to hospital due to GI (gastrointestinal) bleed and all anticoagulants were discontinued. PCG reports that she also noticed the pt would have some dyspnea with exertion." During the joint record review, on 03/05/2024, the DCS confirmed that the physician narrative only contained the one sentence and said, "this is why he is no longer the Medical Director, there was a lot more that he should have included."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. (L670) Each patient’s record includes, at a minimum: Physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) records reviewed revealed the agency did not ensure the clinical records included the certification of terminal illness document. Clinical Record 5: The patient elected the hospice benefit on 02/05/2024 and was discharged on 02/16/2024. The record did not contain the physician certification of terminal illness document. The DCS reported, during the joint clinical record review on 03/05/2024, that the initial certification of terminal illness "was never generated" therefor the clinical record did not contain one.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) record reviewed, in which a patient revoked hospice services, revealed the agency did not ensure the patient's attending physician was provided a copy of the discharge summary. Clinical Record 5: The patient elected the hospice benefit on 02/05/2024 with a diagnosis of senile degeneration of the brain. The patient revoked hospice services as of 02/16/2024. The record did not include evidence that a discharge summary, or any required information from the discharge summary, was provided to the attending physician. During the joint clinical record review, on 03/05/2024, the DCS reported that the section of the discharge summary, where the clinician would report, what information was provided to the attending physician was left blank. It was further reported that there was no additional documented evidence available that would demonstrate adherence to this regulation.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) record reviewed, in which a patient revoked hospice services, revealed the agency did not ensure the patient's attending physician was provided a copy of the discharge summary. Clinical Record 5: The patient elected the hospice benefit on 02/05/2024 with a diagnosis of senile degeneration of the brain. The patient revoked hospice services as of 02/16/2024. The record did not include evidence that a discharge summary, or any required information from the discharge summary, was provided to the attending physician. During the joint clinical record review, on 03/05/2024, the DCS reported that the section of the discharge summary, where the clinician would report, what information was provided to the attending physician was left blank. It was further reported that there was no additional documented evidence available that would demonstrate adherence to this regulation.

It is required that the hospice EP (emergency preparedness) training program includes the following, for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, training of all hospice employees and individuals providing services under arrangement at least every two (2) years, more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by personnel record review and interview. In 2 of 6 (33%) personnel records reviewed, the agency did not ensure staff were provided with emergency preparedness training. Personnel Record 1: Medical Director date of hire 10/12/2023. Review of the personnel record revealed no documented evidence that emergency preparedness training was completed. Personnel Record 3: Director of Patient Care Services /Registered Nurse date of hire 02/23/2023. Review of the personnel record revealed no documented evidence that emergency preparedness training was completed. During joint personnel record review and interview on 01/24/2024, the Administrator agreed that the personnel files were missing documentation of emergency preparedness training.

It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient elected to receive the notice of non-covered items addendum; the agency did not ensure the patient was provided with the information. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Documentation on the consent indicated the patient/representative had elected to receive the notice of non-covered items addendum. Clinical record review revealed the notice of non-covered items addendum in the patient’s chart was blank and did not include a list of non-covered items. During joint clinical record review and interview on 01/25/2024, the Director of Patient Care Services agreed and stated the non-covered items form had not been provided to the patient/representative.

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. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1 (100%) home visit observations, the agency did not ensure the drug profile was updated with the patient's current prescription medications. Home Visit 1/Clinical Record 1: During the home visit observation with a patient that resides in a group home setting, the Registered Nurse (Staff 4) was asked how medication review is completed during a visit. The nurse responded, "I usually do them at least every other week when I order the medication refills for the patient." Review of the patient’s medications in the group home revealed Gabapentin was ordered to take 2 capsules by mouth and the plan of care dated 12/22/2023 ordered Gabapentin take 1 capsule by mouth. The nurse stated she would review and update the medication profile in the clinical record.

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 1 of 2 (50%) clinical records reviewed, the agency did not ensure the initial bereavement assessment included an 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. Clinical Record 2: The patient elected the hospice benefit on 10/12/2023 with a terminal diagnosis of metabolic encephalopathy. The initial bereavement assessment dated 10/12/2023 included documentation by the nurse that stated, "wife refused the social worker." The initial bereavement assessment did not include an assessment of the needs of the patient’s family and the factors that may impact their ability to cope with the patient's death. During a joint clinical record review and interview on 01/24/2024, the Director of Patient Care Services stated the social worker normally completed the bereavement assessment and because this patient refused the social worker, this one was missed.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records and interviews with the Administrator and the Director of Patient Care Services which revealed the following issues with the ability of the Interdisciplinary Group to meet the spiritual needs of the patient/family and the development and implementation of patients’ interdisciplinary care plans: Failure to ensure the entire Interdisciplinary Group supervised the care and services provided to the patient and family [HCPC.1.I/L539]; Failure to ensure the Interdisciplinary Group included an individual qualified as a pastor or other counselor [HCPC.2.D/L541]; Failure to ensure the individualized plan of care included the scope and frequency of services necessary to meet patient and family needs [HCPC.21.I/L547]; and Failure to ensure the Interdisciplinary Group reviewed and revised the individualized plan of care no less frequently than every 15 calendar days [HCPC.22.I/L552]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary Group, Care Planning, and Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the agency did not ensure the entire interdisciplinary group (IDG), including the spiritual counselor and medical director, supervised the care and services provided to the patient and family. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed an IDG meeting was completed on 01/16/2024, but the Spiritual Counselor was not in attendance. Review of the agency’s IDG schedule revealed an IDG meeting should have been completed on 01/02/2024 but the clinical record contained no documented evidence of an IDG meeting for the month of January prior to the 01/16/2024 review. During an interview on 01/23/2024, the Director of Patient Care Services reported that the IDG meeting on January 2nd, 2024, was not held due to the "Medical Director and a Registered Nurse being on vacation and unavailable." Clinical Record 2: The patient elected the hospice benefit on 10/12/2023 with a terminal diagnosis of metabolic encephalopathy. Review of the IDG meetings completed on 10/24/2023, 11/07/2023, 11/21/2023 revealed no documented evidence that the Spiritual Counselor was in attendance. During joint record reviews and interviews, the Director of Patient Care Services confirmed that a Spiritual Counselor had not attended the IDG meetings. During joint record review and interview on 01/23/2024, the Director of Patient Care Services (DPCS) reported that the IDG meeting on January 2nd, 2024, was not held due to the "Medical Director and a Registered Nurse being on vacation." The DPCS confirmed that the agency does not have a designated Alternate Medical Director to provide physician services when the Medical Director is not available. The Administrator and the DPCS also stated they had not "been able to contact the spiritual counselor since October 2023 and had not been providing spiritual counseling services since that date." The Administrator explained they had a personnel file for a Spiritual Counselor from an agency in another state, approximately 1800 miles from the agency. The Administrator stated the Spiritual Counselor was "covering remotely if needed as the part-time local person had been unreachable since October 2023." The Administrator and the DPCS confirmed a Spiritual Counselor from another state had not been attending the agency’s interdisciplinary group meetings and had not provided spiritual counseling services to the agency's patients.

It is required that the hospice Interdisciplinary Group includes, but is not limited to, individuals who are qualified and competent to practice in the following professional roles, pastoral or other counselor(s). This standard is not met as evidenced by clinical record review, personnel record review, and interview. The agency did not ensure the Interdisciplinary Group included an individual qualified as a pastor or other counselor. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed no documented evidence that the Spiritual Counselor participated in the care of the patient. Review of the plan of care, updates to the plan of care, interdisciplinary group meetings, visit notes, and communication notes revealed no evidence that the Spiritual Counselor was involved in the care of the patient and no documentation that the patient had refused Spiritual Counselor services. Clinical Record 2: The patient elected the hospice benefit on 10/12/2023 with a terminal diagnosis of metabolic encephalopathy. Clinical record review revealed no documented evidence that the Spiritual Counselor participated in the care of the patient. Review of the plan of care, updates to the plan of care, interdisciplinary group meetings, visit notes, and communication notes revealed no evidence that the Spiritual Counselor was involved in the care of the patient and no documentation that the patient had refused Spiritual Counselor services. Personnel Record 6: Spiritual Counselor date of hire 04/19/2023, no longer employed by the agency as of October 2023. During a request for personnel records and interview the Administrator explained that the Spiritual Counselor (personnel record 6) had worked for the agency part-time but had been unreachable since October 2023. The Administrator explained that the agency had a Spiritual Counselor from another agency that could cover remotely, if needed. Review revealed the remote Spiritual Counselor resided in another state, approximately 1800 miles from the agency. The Administrator and the Director of Patient Care Services confirmed a Spiritual Counselor had not been attending the agency’s interdisciplinary group meetings and had not been participating in the patients care. The agency was unable to provide evidence that the Interdisciplinary Group included an individual qualified as a pastor or other counselor.

It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the agency did not ensure the individualized plan of care included the scope and frequency of services necessary to meet patient and family needs. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Review of the plan of care revealed it did not include orders for skilled nurse and social worker frequency of visits. Clinical record review revealed skilled nursing visits were scheduled once a week and social worker visits were scheduled once a month, in the scheduling module of the electronic medical record (EMR), but the record contained no documented evidence of a physician order for the skilled nurse and social worker visit frequency. Clinical Record 2: The patient elected the hospice benefit on 10/12/2023 with a terminal diagnosis of metabolic encephalopathy. Review of the plan of care revealed it did not include orders for skilled nurse frequency of visits. Clinical record review revealed skilled nursing visits were scheduled once a week, in the scheduling module of the EMR, but the record contained no documented evidence of a physician order for the skilled nurse visit frequency. During joint clinical record review and interview on 01/25/2024, the Director of Patient Care Services stated she could not locate the orders but "thought they were on the scheduling console."

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed, the agency did not ensure the interdisciplinary group (IDG) reviewed and revised the individualized plan of care no less frequently than every 15 calendar days. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed an IDG review of the plan of care was completed on 01/16/2024. Review of the agency’s IDG schedule revealed an IDG review should have been completed on 01/02/2024 but the clinical record contained no documented evidence of an IDG review for the month of January prior to the 01/16/2024 review. During joint record review and interview on 01/23/2024, the Director of Patient Care Services reported that the IDG meeting on January 2nd, 2024, was not held due to the "Medical Director and a Registered Nurse being on vacation."

It is required that the hospice provides infection control education to employees, contracted providers, patients, family members, and other caregivers that is individualized to the needs of each patient. This standard was not met as evidenced by personnel record review and interview. In 2 of 6 (33%) personnel records reviewed, the agency did not ensure staff were provided with infection control education. Personnel Record 1: Medical Director date of hire 10/12/2023. Review of the personnel record revealed no documented evidence that infection control education was completed. Personnel Record 3: Director of Patient Care Services /Registered Nurse date of hire 02/23/2023. Review of the personnel record revealed no documented evidence that infection control education was completed. During joint personnel record review and interview on 01/24/2024, the Administrator agreed that the personnel files were missing infection control education.

It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by clinical record review and interviews with the Administrator and the Director of Patient Care Services which revealed issues with the agency's ability to provide core services in the following areas: Failure to ensure the core services of a spiritual counselor was provided to patients and families [HCDT.11.I/L598]. The cumulative effect of this deficiency has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard is not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the agency did not ensure spiritual counseling services were available to the patient and family. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed no documented evidence that the Spiritual Counselor participated in the care of the patient. Review of the plan of care, updates to the plan of care, interdisciplinary group meetings, visit notes, and communication notes revealed no evidence that the Spiritual Counselor was involved in the care of the patient and no documentation that the patient had refused Spiritual Counselor services. Clinical Record 2: The patient elected the hospice benefit on 10/12/2023 with a terminal diagnosis of metabolic encephalopathy. Clinical record review revealed no documented evidence that the Spiritual Counselor participated in the care of the patient. Review of the plan of care, updates to the plan of care, interdisciplinary group meetings, visit notes, and communication notes revealed no evidence that the Spiritual Counselor was involved in the care of the patient and no documentation that the patient had refused Spiritual Counselor services. During a joint record review and interview on 01/24/2024, the Administrator and the Director of Patient Care Services stated they had not "been able to contact the spiritual counselor since October 2023 and had not been providing spiritual counseling services since that date." The Administrator explained they had a personnel file for a Spiritual Counselor from an agency in another state, approximately 1800 miles from the agency. The Administrator stated the Spiritual Counselor was "covering remotely if needed as the part-time local person had been unreachable since October 2023." The Administrator and the Director of Patient Care Services confirmed a Spiritual Counselor from another state had not been attending the agency’s interdisciplinary group meetings and had not provided spiritual counseling services to the agency's patients.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard is not met as evidenced by document review and interview. The hospice did not ensure development of a volunteer program. Review of the agency's volunteer program revealed no documented evidence that the agency had developed and implemented a volunteer program. During the request for personnel records on 01/23/2024, the Administrator and the Director of Patient Care Services stated the agency did not have any volunteers. They confirmed the agency did not have volunteers available for day to day administrative or direct care roles. The agency could not provide documentation of recruitment and retaining efforts, cost saving s related to volunteer usage, and could not show proof that volunteers had been used in administrative and direct care roles.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by clinical record review, personnel record review, and interviews with the Administrator and the Director of Patient Care Services which revealed issues with the hospice organizing, managing, and administering its resources to provide hospice care and services to patients, families, and caregivers in the following areas: Failure to ensure Hospice Aide, Spiritual Counselor, and Volunteer services were available to provide care to the agency’s patients and/or families [HCDT.1.i/G652]; Failure to ensure all covered services were available on a 24-hour basis to meet the needs of the patient and family [HCDT.4.I/L653]; and Failure to ensure staff initial skills and competencies were assessed and documented [HSRM.14.I/L663]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice, hospice aides, volunteers, and homemaker services, and counseling services, including spiritual counseling, bereavement counseling, and dietary counseling. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the agency did not ensure Hospice Aide, Spiritual Counselor, and Volunteer services were available to provide care to the agency’s patients and/or families. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed no documented evidence that the Hospice Aide, Spiritual Counselor, and Volunteer participated in the care of the patient. Review of the plan of care, updates to the plan of care, interdisciplinary group meetings, visit notes, and communication notes revealed no evidence that the Hospice Aide, Spiritual Counselor, and the Volunteer were involved in the care of the patient and no documentation that the patient had refused these services. Clinical Record 2: The patient elected the hospice benefit on 10/12/2023 with a terminal diagnosis of metabolic encephalopathy. Clinical record review revealed no documented evidence that the Spiritual Counselor participated in the care of the patient. Clinical record review revealed no documented evidence that the Hospice Aide, Spiritual Counselor, and Volunteer participated in the care of the patient. Review of the plan of care, updates to the plan of care, interdisciplinary group meetings, visit notes, and communication notes revealed no evidence that the Hospice Aide, Spiritual Counselor, and the Volunteer were involved in the care of the patient and no documentation that the patient had refused these services. During the request for personnel records on 01/23/2024, the site visitor was advised that the agency did not have a Hospice Aide or a Volunteer. When asked how the agency provides these services to patients the Administrator and the Director of Patient Care Services stated Aide services were being provided by "caregivers at the group home where the patient resided." The agency had a personnel file for a Spiritual Counselor from an agency in another state, approximately 1800 miles from the agency. The Administrator state the Spiritual Counselor was "covering remotely if needed as the part-time local person had been unreachable since October 2023." The Administrator and the Director of Patient Care Services confirmed a Spiritual Counselor had not been attending the agency’s interdisciplinary group meetings. The agency did not ensure the care and services of an aide, spiritual counselor, and volunteer were provided in a manner consistent with accepted standards of practice.

It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the agency did not ensure all covered services, including spiritual counseling services, were available on a 24-hour basis to meet the needs of the patient and family. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed no documented evidence that the Spiritual Counselor participated in the care of the patient. Review of the plan of care, updates to the plan of care, interdisciplinary group meetings, visit notes, and communication notes revealed no evidence that the Spiritual Counselor was involved in the care of the patient and no documentation that the patient had refused Spiritual Counselor services. Clinical Record 2: The patient elected the hospice benefit on 10/12/2023 with a terminal diagnosis of metabolic encephalopathy. Clinical record review revealed no documented evidence that the Spiritual Counselor participated in the care of the patient. Review of the plan of care, updates to the plan of care, interdisciplinary group meetings, visit notes, and communication notes revealed no evidence that the Spiritual Counselor was involved in the care of the patient and no documentation that the patient had refused Spiritual Counselor services. During a joint record review and interview on 01/24/2024, the Administrator and the Director of Patient Care Services stated they had not "been able to contact the spiritual counselor since October 2023 and had not been providing spiritual counseling services since that date." The Administrator explained they had a personnel file for a Spiritual Counselor from an agency in another state, approximately 1800 miles from the agency. The Administrator stated the Spiritual Counselor was "covering remotely if needed as the part-time local person had been unreachable since October 2023." The Administrator and the Director of Patient Care Services confirmed a Spiritual Counselor from another state had not been attending the agency’s interdisciplinary group meetings and had not provided spiritual counseling services to the agency's patients.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review and interview. In 4 of 6 (67%) personnel records reviewed, the agency did not ensure staff initial skills and competencies were assessed and documented. Personnel Record 1: Medical Director date of hire 10/12/2023. Review of the personnel record revealed no documented evidence that an initial competency assessment was completed. Personnel Record 3: Director of Patient Care Services /Registered Nurse date of hire 02/23/2023. Review of the personnel record revealed no documented evidence that an initial competency assessment was completed. Personnel Record 5: Social Worker date of hire 11/21/2023. Review of the personnel record revealed no documented evidence that an initial competency assessment was completed. Personnel Record 6: Spiritual Counselor date of hire 04/19/2023, no longer employed by the agency as of October 2023. Review of the personnel record revealed no documented evidence that an initial competency assessment was completed. During joint personnel record review and interview on 01/24/2024, the Administrator agreed that the personnel files were missing the initial competencies.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by clinical record review and interview. The agency did not ensure an Alternate Medical Director was available to provide oversight of the hospice patient's care, when the Medical Director was unavailable. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed an IDG [Interdisciplinary Group] review of the plan of care was completed on 01/16/2024. Review of the agency’s IDG schedule revealed an IDG review should have been completed on 01/02/2024 but the clinical record contained no documented evidence of an IDG review for the month of January prior to the 01/16/2024 review. During joint record review and interview on 01/23/2024, the Director of Patient Care Services (DPCS) reported that the IDG meeting on January 2nd, 2024, was not held due to the "Medical Director and a Registered Nurse being on vacation." The DPCS confirmed that the agency does not have a designated Alternate Medical Director to provide physician services when the Medical Director is not available.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed, the agency did not ensure the Medical Director provided written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. Clinical Record 1: The patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the certification of terminal illness was not signed by the hospice Medical Director, as of the date of record review on 01/23/2024. During joint clinical record review and interview on 01/23/2024, the Director of Patient Care Services stated they "thought it had been signed earlier."

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. This standard was not met as evidenced by personnel record review and interview. In 4 of 6 (67%) personnel records reviewed, the agency did not ensure criminal background checks were completed for staff with direct patient contact or access to patient records. Personnel Record 1: Medical Director date of hire 10/12/2023. Review of the personnel record revealed no documented evidence that a background check was completed for this direct patient contact employee. Personnel Record 2: Administrator date of hire 09/01/2023. Review of the personnel record revealed no documented evidence that a background check was completed for this employee with access to patient records. Personnel Record 4: Registered Nurse date of hire 12/18/2023. Review of the personnel record revealed no documented evidence that a background check was completed for this direct patient contact employee. Personnel Record 5: Social Worker date of hire 11/21/2023. Review of the personnel record revealed no documented evidence that a background check was completed for this direct patient contact employee. During a joint personnel record review and interview on 01/24/2024, the Administrator stated they could not locate the background checks.