Every finding on record at We Care Hospice, Inc.

It is required that a hospice aide provides services Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed for patients that elected aide services revealed the agency did not ensure the hospice aide provided services as ordered on the aide care plan. CONTINUING REQUIRED ACTION CLINICAL RECORD 2: The patient elected the hospice benefit 01/14/2025 with diagnosis of Cerebral atherosclerosis. The plan of care for 01/14/2025 included an order for the hospice aide three times a week. The aide care plan dated 01/14/2025 included the tasks "Change Linen", "Light Housekeeping", "Make Bed", and "Turn or Position" every visit. The aide visit notes dated 04/09/2025 and 04/11/2025, the aide documented "NA" for the ordered tasks "Change Linen", "Light Housekeeping", "Make Bed", and "Turn or Position". The record lacked evidence of supportive documentation as to the reason "Change Linen", "Light Housekeeping", "Make Bed", and "Turn or Position" were not "Done" when the task was ordered. CLINICAL RECORD 3: The patient elected the hospice benefit 03/13/2025 with diagnosis of Cerebral atherosclerosis. The plan of care dated 03/13/2025-06/10/2025 included an order for hospice aide two times a week. The aide care plan dated 03/13/2025 included the tasks "Foot Care", "Light Housekeeping", and "Range of Motion" every visit. The aide visit notes dated 04/09/2025 and 04/14/2025, the aide documented "NA" for the ordered tasks "Foot Care", "Light Housekeeping", and "Range of Motion". The record lacked evidence of supportive documentation as to the reason "Foot Care", "Light Housekeeping", and "Range of Motion" were "NA" and not "Done" when the task was ordered. CLINICAL RECORD 4: The patient elected the hospice benefit 03/04/2025 with diagnosis of Chronic obstructive pulmonary disease. The plan of care dated 03/04/2025 - 04/10/2025 included an order for the hospice aide two times a week. The aide care plan dated 03/04/2025 included the task "Incontinent Care" every visit. The aide visit note dated 03/05/2025, the aide documented "NA" for the ordered tasks "Incontinent Care". The record lacked supportive documentation as to the reason "Incontinent Care" was "NA" and not "Done" when the task was ordered. The Director of Patient Care Services stated in an interview on 04/15/2025 that the agency did not ensure that the aide provided services included on the aide care plan. She also stated the "NA" meaning not applicable is being utilized and the answer should be either "Done" or "Not Done" with a supportive reason for "Not Done". CONTINUATION OF REQUIRED ACTION

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure the aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan. CONTINUING REQUIRED ACTION CLINICAL RECORD 2: The patient elected the hospice benefit 01/14/2025 with diagnosis of Cerebral atherosclerosis. The plan of care for 01/14/2025 included an order for the hospice aide three times a week. The aide care plan dated 01/14/2025 included the tasks "Change Linen", "Light Housekeeping", "Make Bed", and "Turn or Position" every visit. The aide visit notes dated 04/09/2025 and 04/11/2025, the aide documented "NA" for the ordered tasks "Change Linen", "Light Housekeeping", "Make Bed", and "Turn or Position". The record lacked documented evidence that the aide notified the RN of the above changes in the patient's medical needs as related to the ordered tasks "Change Linen", "Light Housekeeping", "Make Bed", and "Turn or Position". CLINICAL RECORD 3: : The patient elected the hospice benefit 03/13/2025 with diagnosis of Cerebral atherosclerosis. The plan of care dated 03/13/2025-06/10/2025 included an order for hospice aide two times a week. The aide care plan dated 03/13/2025 included the tasks "Foot Care", "Light Housekeeping", and "Range of Motion" every visit. The aide visit notes dated 04/09/2025 and 04/14/2025, the aide documented "NA" for the ordered tasks "Foot Care", "Light Housekeeping", and "Range of Motion". The record lacked documented evidence that the aide notified the RN of the above changes in the patient's medical needs as related to the ordered tasks "Foot Care", "Light Housekeeping", and "Range of Motion". CLINICAL RECORD 4: The patient elected the hospice benefit 03/04/2025 with diagnosis of Chronic obstructive pulmonary disease. The plan of care dated 03/04/2025 - 04/10/2025 included an order for the hospice aide two times a week. The aide care plan dated 03/04/2025 included the task "Incontinent Care" every visit. The aide visit note dated 03/05/2025, the aide documented "NA" for the ordered tasks "Incontinent Care". The record lacked documented evidence that the aide notified the RN of the above changes in the patient's medical needs as related to the ordered tasks "Incontinent Care". The Director of Patient Care Services stated in an interview on 04/15/2025 that the agency did not ensure that the aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan. CONTINUATION OF REQUIRED ACTION

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure an initial assessment was completed within 48 hours of the patient’s election of hospice care. Agency Policy No C: 3-1062, Documentation (no date), stated in relevant part: "3. All documentation shall be completed and submitted within forty-eight hours of the visit." CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2025 for a diagnosis of cerebral atherosclerosis. As of 03/06/2025 the clinical record lacked documented evidence of the initial nursing assessment, making it 6 days outstanding. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/01/2025 for a diagnosis of Alzheimer's disease. As of 03/06/2025 the clinical record lacked documented evidence of the initial nursing assessment, making it 4 days outstanding. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 and the Clinical Supervisor stated, "the assessments had not been entered as he was not finished charting."

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Agency Policy No C: 3-1062, Documentation Policy No C; 3:1062 (no date), stated in relevant part, "3. All documentation shall be completed and submitted within forty-eight hours of the visit." CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2025. The clinical record lacked evidence of a completed initial bereavement assessment as of the date of review on 03/06/2025. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/17/2025. The clinical record lacked evidence of a completed initial bereavement assessment as of the date of review on 03/06/2025. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 and the Clinical Supervisor stated, "the assessments had not been entered as he was not finished charting."

It is required that a hospice aide provides services ordered by the interdisciplinary group and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 5 of 8 (63%) clinical records reviewed, in which hospice aide services were accepted, revealed the agency did not ensure the aide provided services included in the plan of care as ordered by the Interdisciplinary Group. Clinical Record 1/Home Visit 1: The hospice aide care plan (POC) dated 02/12/2025 included the following tasks: "Bed bath, assistance with dressing, peri care, skin care, comb hair, shampoo hair, check pressure areas, light housekeeping, change linens, turn or position, incontinent care and vital signs." These tasks were ordered to be completed every visit. The hospice aide visit frequency was three times per week. During the home visit conducted with the Hospice Aide (Personnel Record 5) on 03/06/2025, the aide did not complete the tasks of shampooing the hair or changing linens. After the visit, the aide advised the surveyor she had "asked the (RN/Clinical Supervisor) for the care plan to be changed multiple times to weekly for those two items but it hadn't been changed yet." The clinical record revealed a hospice aide visit note dated 02/14/2025 marked the tasks of light housekeeping and checking pressure areas every visit as "NA (not applicable)."There was no additional documentation as to why the tasks were not performed. CLINICAL RECORD 5: The hospice aide care plan dated 05/12/2024 included the tasks of light housekeeping, combing patient's hair, shampoo hair, changing linens and make the bed every visit. The hospice aide visit note dated 12/10/2024 marked the tasks of comb hair and light housekeeping as "NA.” The hospice aide visit note dated 02/05/2025 marked the tasks of shampoo hair, changing linen, make bed, and light housekeeping as "NA". There was no additional documentation as to why the tasks were not performed. CLINICAL RECORD 7: The hospice aide care plan dated 01/25/2025 included the task of assisting with ambulation every visit. However, the hospice aide visit notes dated 02/17/2025 and 02/26/2025 marked this task as "NA." There was no additional documentation as to why the tasks were not performed. CLINICAL RECORD 9: The hospice aide care plan dated 02/17/2025 included the tasks of assist to dress, bed bath, skin care, shower, turn and position every visit. The hospice aide visit note dated 02/19/2025 noted "refused bed bath” and marked ‘NA’ for “turn and position." The hospice aide visit note dated 02/26/2025 stated ‘NA’ for “bed bath, shower and turn and position." The hospice aide visit note dated 03/03/2025 stated ‘NA’ for “assist to dress, bed bath, skin care, shower, turn and position." There was no additional documentation as to why the tasks were not performed. CLINICAL RECORD 10: The hospice aide care plan dated 08/01/2024 included the tasks of light housekeeping and change linens every visit. The hospice aide visit notes dated 02/03/2025 and 03/03/2025 had a notation that a "shower was completed." The aide had checked ‘NA’ to the tasks of “change linens and light housekeeping." There was no additional documentation as to why the tasks were not performed. The task of shower was not listed on the hospice aide care plan. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 in which he confirmed "the aide care plans needed to be updated to reflect the care being provided currently." He also confirmed he had previously "received notification from the aide about the care plans that needed to be changed."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (13%) clinical records reviewed, in which hospice aide services were accepted, revealed the agency did not ensure the aide reported changes in the patient’s medical, nursing, rehabilitative, and/or social need to a registered nurse as the changes related to the plan of care. CLINICAL RECORD 14: The hospice aide care plan dated 01/08/2025 included the task of showering patient every visit. The hospice aide visit note dated 01/09/2025 stated "Patient was seen. He refused shower/care. Stated he would rather sit outside for sun and then go back to bed." The hospice aide visit note dated 01/11/2025 stated "Patient refused care. Complaint of not feeling well. Vitals done." There was no documentation that the registered nurse (RN) was notified the patient was not feeling well or the refusal of cares. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 in which he confirmed there was no documentation of RN notification.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 8 (38%) clinical records reviewed revealed the agency did not ensure that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days CLINICAL RECORD 1: The Plan of Care (POC) effective as of 01/31/2025 ordered hospice aide visits twice weekly throughout the POC, beginning on 02/03/2025. The record lacked evidence of an aide supervisory visit to date, seventeen days outstanding. CLINICAL RECORD 7: The Plan of Care (POC) effective as of 01/25/2025 ordered hospice aide visits twice weekly throughout the POC. The last documented aide supervisory visit was on 02/04/2025. The record lacked evidence of an aide supervisory visit on 2/20/2025. CLINICAL RECORD 9: The Plan of Care (POC) effective as of 02/17/2025 ordered hospice aide visits twice weekly throughout the POC. The record lacked evidence of a Hospice Aide supervisory visit on 03/03/2025. An interview with the Clinical Supervisor on 03/07/2025 he stated, "he thinks he needs to document those visits still."

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 CONDITION was not met as evidenced by document review and interviews with the Volunteer Coordinator and Clinical Supervisor, which revealed the hospice: Failed to provide day-to-day administrative or direct patient services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff [HSLG.7.I/L647]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to provide quality care for the Condition of Participation CFR 418.76: Volunteers. The collective deficient practice illustrated not having a process to ensure the provision of volunteer services to all patients.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review were conducted with the Volunteer Coordinator and Clinical Supervisor on 03/06/2025 who reported that agency did not have any volunteer hours documented for the past year (February 2024 to February 2025) in either an administrative or patient care role, making the volunteer percentage 0%. Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review was conducted with the Volunteer Coordinator and Clinical Supervisor on 03/06/2025 The agency did not have any volunteer hours documented for the past year (February 2024 to February 2025) in either an administrative or patient care role, making the volunteer percentage 0%.

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. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 6 (33%) personnel records reviewed revealed the agency did not ensure the hospice assessed the skills and competencies of all individuals providing care. Agency Policy No C:3-023-1, Competency Program (no date), stated in relevant part, "1. The organization will establish and annually re-evaluate its job-specific competency-based orientation checklist which reflects duties commonly required in the performance of patient contact positions." Personnel Record 2: A Registered Nurse with date of hire 08/06/2020 providing direct patient care lacked documentation of a skills competency for 2022, 2023, 2024. The last documented skills competency was dated in 2021. Personnel Record 3: A Social Worker with date of hire 11/25/2019 providing direct patient care lacked documentation of a skills competency for 2022, 2023, 2024. The last documented skills competency was dated in 2019. A joint record review was conducted with the Office Coordinator on 03/06/2025 and the competencies were unable to be located for the missing years.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed, that required recertification of terminal illness, revealed the agency did not ensure written and signed recertification to meet the hospice care benefit requirement was completed. CLINICAL RECORD 3: The clinical record lacked documentation of the recertification of terminal illness for the third benefit period, which began on 11/29/2024. CLINICAL RECORD 10: The clinical record lacked documentation of the recertification of terminal illness for the second benefit period, which began on 01/27/2025. In an interview conducted on 03/06/2025 the Administrator/Medical Director advised he "thought they had all been completed in a timely manner.” At the time of the exit conference the agency was unable to produce these documents.

It is required that a patient clinical record 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. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed, it was revealed that the agency did not ensure the clinical record included physician orders for the hospice patient’s medication. Agency Policy No C:3-1062, Documentation (no date), stated in relevant part: "3. All documentation shall be completed and submitted within forty-eight hours of the visit." CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2025 for the diagnosis of cerebral atherosclerosis. A review of the clinical record on 03/06/2025 revealed no evidence of medication orders identified in the plan of care. The clinical record only contained the scanned hospital discharge medication list received with the referral but did not include physician orders for the medications the patient was taking while on hospice services. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/01/2025 for the diagnosis of Alzheimer's disease. A review of the clinical record on 03/06/2025 revealed there were no medication orders documented in the clinical record or identified in the plan of care; however, the nursing visit notes indicated the patient was taking medications. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/17/2025 for the diagnosis of heart failure. A review of the clinical record on 03/06/2025 revealed the only medication documented in the clinical record or identified in the plan of care was oxygen. An interview with the Clinical Supervisor on 03/06/2025 indicated the patient was on "more medications but these had not been entered in the clinical record yet." The clinical record did not include physician orders for the medications the patient was taking while on hospice services. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 and the Clinical Supervisor stated, "the medications had not been entered as he was not finished charting."

It is required that information management policies and procedures (P&P) address how the hospice documents, collects, retrieves, protects, shares, and retains information in accordance with state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review, and interview. In 14 of 14 (100%) clinical records reviewed revealed the agency did not ensure the documents were stored in accordance with hospice policy. Agency Policy C:2-031.1, Safeguarding/Retrieval of Clinical/Service Record (no date), stated in relevant part, "1. All patient clinical/service records will be maintained in a locked, waterproof file cabinet in a record room: A. The files will be locked at night. B. The clinical/service record room will be locked at night… 3. The original clinical/service record for active patients will remain in the office at all times… 8. Organization personnel will return any and all clinical/service record contents or copies of such to the office for destruction no later than the time of discharge." A clinical record review was conducted on 03/05/2025 with the Clinical Supervisor. During the review, the notice of elections, the advance directives, and informed consents were requested for Clinical Records 1 through 14. In an interview the Clinical Supervisor stated these documents were "stored at his house in the garage." He further went on to state he "lived approximately 1 1/2 hours from the office and didn't come to the office that often to turn in paperwork." It was requested he produce the documents; the next day he brought them to the office in a banker's box for review. They were then scanned into the clinical records. A clinical record review was conducted on 03/05/2025 with the Clinical Supervisor. During the review, the notice of election, the advance directive, and informed consent were requested for Clinical Records 1 through 14. The Clinical Supervisor stated these documents were "stored at his house in the garage." He further went on to state he "lived approximately 1 1/2 hours from the office and didn't come to the office that often to turn in paperwork." It was requested he produce the documents the next day and he brought them to the office in a banker's box for review. They were then scanned into the clinical record.

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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed which required a discharge summary, it was revealed that the agency did not ensure the discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 11: The patient was discharged on 03/22/2024. The discharge summary dated 03/22/2024 stated in its entirety "patient relocated to {name of city} and discharged." It did not include at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 12: The patient elected to revoke their hospice benefit on 04/05/2024. The discharge summary dated 04/05/2024 stated in its entirety "The patient was transferred to the hospital to seek aggressive treatment." It did not include at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 in which he stated, "I did not know to include all of that information."

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 2 of 2 (100%) clinical records reviewed of patients who expired revealed the hospice did not ensure a completed post death bereavement plan of care. Clinical Record 4: The patient’s benefit election was dated 6/2/2023. The patient's death was dated 7/12/2023. There was no evidence of a post death bereavement assessment or a bereavement plan of care. Clinical Record 5: The patient’s benefit election was dated 12/15/2022. The patient's death was dated 1/9/2023. There was no evidence of a post death bereavement assessment or a bereavement plan of care. Document 1: The agency policy titled Bereavement Services Policy No. H:2-008.1 (revised 4/2018) stated in relevant parts "After a death has occurred, the bereavement assessment will be updated.." and "Within 2 weeks after the death of a patient, a sympathy card will be sent to the bereaved." and "After 3 weeks, a bereavement letter with be sent to the bereaved" and "Within 3-5 weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor." An interview with the DPCS who reviewed records with this site visitor on 12/5/2023 confirmed this finding. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 2 of 2 (100%) clinical records reviewed of patients who expired revealed the hospice did not ensure a completed post death bereavement plan of care.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 2 of 3 (67%) clinical records reviewed of patients requiring recertification revealed the hospice did not ensure a verbal or written recertification was completed. In 1 of 1 (100%) clinical record reviewed of patients requiring a face-to-face encounter revealed the hospice did not ensure a face-to-face encounter was completed. Clinical Record 2: The patient’s benefit election was dated 4/21/2023. Benefit period #12 was dated 4/21/2023-6/19/2023. There was no evidence of a written certification of terminal illness. The face-to-face encounter was documented on 5/31/2023. Benefit period #13 was dated 6/20/2023-8/18/2023. There was no evidence of a verbal or written certification of terminal illness. There was no evidence of a face-to-face encounter prior to the start of the benefit period. Benefit period #14 was dated 8/19/2023-10/17/2023. There was no evidence of a written certification of terminal illness. There was no evidence of a face-to-face encounter prior to the start of the benefit period. Benefit period #15 was dated 10/18/2023-12/16/2023. There was no evidence of a face-to-face encounter prior to the start of the benefit period. Clinical Record 3: The patient’s benefit election was dated 11/24/2023. The was no evidence of a written certification of terminal illness. An interview with the DPCS who reviewed records with this site visitor on 12/5/2023 confirmed this finding. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 2 of 3 (67%) clinical records reviewed of patients requiring recertification revealed the hospice did not ensure a verbal or written recertification was completed. In 1 of 1 (100%) clinical record reviewed of patients requiring a face-to-face encounter revealed the hospice did not ensure a face-to-face encounter was completed.

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). This standard was not met as evidenced by a review of clinical records and interviews. 2 of 8 (25%) clinical records reviewed revealed the hospice did not ensure spiritual counselor visits followed the visit frequencies in the plan of care and/or physician's orders. . THIS IS A CONTINUING PRIOR REQUIRED ACTION. Clinical Record 4: Clinical record was reviewed and identified the spiritual counselor visit frequency of "1 per month" on the IDG plan of care dated 7/15/22 and 7/28/22. Review of clinical record revealed one missing spiritual counselor visit for July 2022. During joint clinical record review and interview on 8/30/22, the Office Coordinator with the Administrator present stated she could not locate the missing spiritual counselor visit, a missed visit report, and/or physician's orders/plan of care for the missing spiritual counselor visit. Clinical Record 3: Clinical record was reviewed and identified the spiritual counselor visit frequency of "1 per month" on the IDG plan of care dated 7/15/22 and 7/28/22. Review of clinical record revealed one missing spiritual counselor visit for July 2022. During joint clinical record review and interview on 8/30/22, the Office Coordinator with the Administrator present stated she could not locate the missing spiritual counselor visit, a missed visit report, and/or physician's orders/plan of care for the missing spiritual counselor visit. THIS IS A CONTINUING PRIOR REQUIRED ACTION.

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. 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 a review clinical records and interviews.1 of 1 (100%) applicable clinical records reviewed of patients who expired revealed the hospice did not ensure an accurately completed post death bereavement plan of care. Clinical Record 0: Clinical record was reviewed and revealed the patient expired 8/7/22. The post death bereavement assessment phone call 8/10/22 identified the bereaved as low risk. The post death bereavement plan of care included, "phone call 1 per week" and "mailing end of bereavement one per week". Phone calls did not occur for the weeks of 8/14/22 and 8/21/22, and missing were the weekly "end of bereavement" mailing the weeks of 8/7/22, 8/14/22 and 8/21/22, as assigned on the bereavement plan of care. During joint review of the clinical record and interview 8/30/22, the Office Coordinator with the Administrator present stated she could not locate the missing phone calls and/or mailings. Additionally during phone interview 8/30/22, with the Office Coordinator and Administrator present, the Bereavement Counselor stated "The electronic medical record does not give me the frequency options of the phone calls and mailings that I wanted so I selected "one per week", even though that is not what I planned to do".

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 a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review clinical records and interviews. 4 of 5 (80%) applicable clinical records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the registered nurse assigned specific written instructions for the type of bathing to be provided to the hospice patient. . Clinical Record 6: Clinical record review for period 8/1/22-8/29/22, identified the hospice aide plan of care assigned the hospice aide to perform "complete bed bath, partial bath/shower, and complete shower" each visit. There was no documented additional instructions on when to complete a bed bath, partial bath/shower, and/or complete shower. The hospice aide plan of care did not include specific written instructions on the type of bath to perform each visit. Clinical Record 3 Clinical record review for period 7/22/22-8/22/22, identified the hospice aide plan of care assigned the hospice aide to perform "complete bed bath, partial bath/shower, and complete shower" each visit. There was no documented additional instructions on when to complete a bed bath, partial bath/shower, and/or complete shower. The hospice aide plan of care did not include specific written instructions on the type of bath to perform each visit. Clinical Record 5: Clinical record review for period 7/22/22-8/22/22, identified the hospice aide plan of care assigned the hospice aide to perform "complete bed bath, partial bath/shower, and complete shower" each visit. There was no documented additional instructions on when to complete a bed bath, partial bath/shower, and/or complete shower. The hospice aide plan of care did not include specific written instructions on the type of bath to perform each visit. Clinical Record 4: Clinical record review for period 7/22/22-8/22/22, identified the hospice aide plan of care assigned the hospice aide to perform "complete bed bath, partial bath/shower, and complete shower" each visit. There was no documented additional instructions on when to complete a bed bath, partial bath/shower, and/or complete shower. The hospice aide plan of care did not include specific written instructions on the type of bath to perform each visit. During joint record review and interview 8/30/22, the Office Coordinator with the Administrator present, confirmed the aide plan of care assigned "complete bed bath, partial bath/shower, and complete shower each visit". During joint record review and interview 8/30/22, the Office Coordinator with the Administrator present, confirmed the aide plan of care assigned "complete bed bath, partial bath/shower, and complete shower each visit".

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by a review clinical records, document review and interview. 8 of 8 (100%) clinical records reviewed revealed the hospice did not ensure COVID-19 screening was completed and documented in the clinical record when making a patient visit, as required in hospice policy. During interview 8/30/22, the Administrator stated the staff are screening the patients each visit but not documenting the COVID-19 screening process in the clinical records, other than temperatures taken by the nurses. During joint review of the clinical records and interview 8/30/22, the Office Coordinator with the Administrator present stated she could not locate the documented COVID-19 screening of the patients. . Clinical Record 1: Clinical record was reviewed 7/22/22 through 8/22/22. Review of the documentation in the clinical record revealed missing documentation of COVID-19 screening of the patient before or immediately upon arrival to the home, as required in agency policy. Clinical Record 5: Clinical record was reviewed 7/22/22 through 8/22/22. Review of the documentation in the clinical record revealed missing documentation of COVID-19 screening of the patient before or immediately upon arrival to the home, as required in agency policy. Clinical Record 6: Clinical record was reviewed 8/1/22 through 8/30/22. Review of the documentation in the clinical record revealed missing documentation of COVID-19 screening of the patient before or immediately upon arrival to the home, as required in agency policy. Clinical Record 0: Clinical record was reviewed and the patient elected hospice care on 7/25/22 and expired 8/7/22. Review of the documentation in the clinical record revealed missing documentation of COVID-19 screening of the patient before or immediately upon arrival to the home, as required in agency policy. Clinical Record 2 Clinical record was reviewed 7/22/22 through 8/22/22. Review of the documentation in the clinical record revealed missing documentation of COVID-19 screening of the patient before or immediately upon arrival to the home, as required in agency policy. Clinical Record 7 Clinical record was reviewed 8/27/22 through 8/30/22. The initial nursing assessment was completed and documented 8/27/22 and did not include COVID-19 screening of the patient before or immediately upon arrival to the home, as required in agency policy. Clinical Record 4: Clinical record was reviewed 7/22/22 through 8/22/22. Review of the documentation in the clinical record revealed missing documentation of COVID-19 screening of the patient before or immediately upon arrival to the home, as required in agency policy. Clinical Record 3: Clinical record was reviewed 7/22/22 through 8/22/22. Review of the documentation in the clinical record revealed missing documentation of COVID-19 screening of the patient before or immediately upon arrival to the home, as required in agency policy. During interview 8/30/22, the Administrator stated the staff are screening the patients each visit but not documenting the COVID-19 screening process in the clinical records. During joint review of the clinical records and interview 8/30/22, the Office Coordinator with the Administrator present stated she could not locate the documented COVID-19 screening of the patients.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 5 (20%) applicable clinical records reviewed of patients requiring recertification revealed the hospice did not ensure a verbal or written recertification was completed. 1 of 4 (25%) applicable clinical records reviewed of patients requiring recertification face to face encounters revealed the hospice did not ensure a face to face encounter with the patient was completed within 30 days prior to the 4th benefit period. . Clinical Record 3: Clinical record was reviewed and revealed the recertification for the 2nd benefit period was due 8/21/22. During joint review of the clinical record and interview 8/30/22, the Office Coordinator with the Administrator present stated she could not locate the recertification for the 2nd benefit period which was due 8/21/22. Clinical Record 5: Clinical record was reviewed and identified the patient elected hospice services 12/17/21. Review of the clinical record revealed the recertification face to face encounter was not completed for the 4th benefit period 8/14/22 through 10/12/22. During joint review of the clinical record and interview 8/30/22, the Office Coordinator with the Administrator present stated she could not locate the physician's face to face encounter visit for the 4th benefit period which started 8/14/22. Policy "Certification of Terminal Illness", Policy No. H:2-025, revised April 2018, included, "The hospice physician or nurse practitioner must have a face to face encounter with the patient within the 30 days prior to the third benefit period recertification and within 30 days prior to each subsequent recertification period".

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records. 1 of 4 (25%) records reviewed for patients admitted after 6/2/2022 revealed the hospice did not ensure that the Interdisciplinary Group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Record #1 was reviewed and revealed the patient elected hospice care on 6/18/2022. The record did not include documented evidence that the medical social worker completed an initial comprehensive assessment.

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 reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) clinical records reviewed revealed the hospice did not ensure an update of the comprehensive assessment by the interdisciplinary group (IDG) occurred as frequently as the condition of the patient requires, but no less frequently than every 15 days. Record #5: The Registered Nurse (RN) recertification visit was documented as completed on 6/7/22. The next RN comprehensive assessment was documented as completed on 6/24/22, 17 days outstanding. The Office Coordinator confirmed during an interview that the record did not contain evidence of a comprehensive assessment that was completed every 15 days.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This CONDITION was not met as evidenced by a review of patient records and interview. The hospice failed as follows: to ensure care and services furnished to the patient followed the individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any) [HCPC.19.I/L543]; to ensure plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care [HCPC.21.I/L548]; to ensure the IDG reviewed, revised, and documented the individualized plan of care no less frequently than every 21 days per the CMS PHE waiver guidelines [HCPC.22.I/L552]. The cumulative effect of these systemic problems resulted in the hospice's inability to ensure the provision of quality patient care in a safe environment. This is a CMS CONDITION level finding. This CONDITION was not met as evidenced by a review of patient records and interview. The hospice agency failed as follows: The agency failed to provide coordination of care and to ensure continuous assessment of each patient’s and family's needs and implementation of the interdisciplinary plan of care.[HCPC.19.I/L540]; to ensure a pastor or other counselor was part of the interdisciplinary group [HCPC.2.D/L541]; to ensure plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care [HCPC.21.I/L548]. to ensure the IDG reviewed, revised, and documented the individualized plan of care no less frequently than every 15 calendar days [HCPC.22.I/L552]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality patient care in a safe environment This is a CMS CONDITION level finding.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 6 (50%) records reviewed revealed the hospice did not ensure that care and services furnished to the patients followed the individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any). Record #1 was reviewed and identified that the patient elected hospice care on 6/18/2022. The record did not include evidence of nursing visits documented as completed for the period of 6/22/22 until after the patient's death on 7/3/22. Record #2 was reviewed and revealed the patient elected hospice care on 2/8/2022. For the certification period dated 6/8/22-8/6/22, the record revealed documentation of a completed chaplain visit dated 6/20/22. There was no evidence of a physician order for spiritual counseling prior to 6/30/22. In addition, the aide visits were documented as completed twice weekly during the weeks of 6/7/22, 6/12/22, and 6/26/22. The plan of care did not document an aide visit frequency and there was no documented evidence that the IDG ordered aide visits. Record #5 was reviewed and revealed the patient elected hospice care on 3/14/22. A chaplain visit was documented as completed on 6/20/22. There was no documented evidence of a physician order for spiritual counseling prior to 6/30/22. The Office Coordinator confirmed this finding during an interview and a joint clinical record review. The Office Coordinator confirmed that the aide visits had been scheduled but there were no documented orders for the aide visits to be performed. The Hospice Medical Director confirmed the finding during an interview and stated that the needs of the patients were met by the skilled nursing facility staff where the patient resided and not by skilled nurses working for the hospice agency during the last 11 days of the patient's life.

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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 6 of 6 (100%) records reviewed revealed the hospice did not ensure that the patient's plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Record #3 was reviewed and identified that the patient elected hospice care on 6/21/2022. The plan of care documented, "Musculoskeletal; Goal: “Fall will not be happen within 1 certification period." The plan of care was missing documentation of measurable outcomes. . Record #4 was reviewed and identified that the patient elected hospice care on 6/12/2022. The plan of care documented, "Problem... Musculoskeletal... Goal: Weakness...Problem: Respiratory; Goal: SOB. The plan of care was missing documentation of measurable outcomes. . Record #1 was reviewed and identified that the patient elected hospice care on 6/18/2022. The plan of care documented, "Problem: Musculoskeletal; Goal: Fall is prevented within the safest level... Problem: Neurological Goal: Confusion and disoriented... Problem: Musculoskeletal Goal: Fatigues and weaknesses managed within comfort levels." The plan of care was missing documentation of measurable outcomes. Record #5 was reviewed and identified that the patient elected hospice care on 3/14/2022. The plan of care documented, "Problem: Neurological; Goal: confusion and disoriented are managed within comfort levels...Problem: Musculoskeletal; Goal: Weakness managed within comfort levels." The plan of care was missing documentation of measurable outcomes. Record #0 was reviewed and identified that the patient elected hospice care on 6/16/2022. The plan of care documented, "Problem: Respiratory; Goal: Coughing management within comfort levels...Problem: Respiratory; Goal: Dyspnea." The plan of care was missing documentation of measurable outcomes. Record #2 was reviewed and identified that the patient elected hospice care on 2/8/2022. The plan of care documented, "Problem: GU/Urinary elimination; Goal: Incontinence urination managed within comfort levels... Problem: Neurological; Goal: Anxiety management within comfort levels." The plan of care was missing documentation of measurable outcomes. During the interview, the Administrator confirmed the records included non-measurable outcomes, and requested resources for training the IDG members on how to develop plans of care with measurable outcomes. The written plans of care in the following records included the non-measurable outcomes as confirmed by the agency Administrator during interview:

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 no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) of records reviewed of patients receiving hospice services for greater than 15 days revealed that the hospice did not ensure that the Interdisciplinary Group (IDG) reviewed, revised, and documented the plan of care no less frequently than every 21 days per the CMS PHE waiver guidelines. Record #2 was reviewed and identified that the patient elected hospice care on 2/8/22. The record included documented evidence that the IDG reviewed the patient's care plan on 6/2/22. The next documented IDG review of the patient's care plan was dated 6/30/22. The record did not include documented evidence that the IDG reviewed the care plan every 21 calendar days. Record #5 was reviewed and identified that the patient elected hospice care on 3/14/22. The record included documented evidence that the IDG reviewed the patient's care plan on 6/2/22. The next documented IDG review of the patient's care plan was dated 6/30/22. The record did not include documented evidence that the IDG reviewed the care plan every 21 calendar days. During an interview, the Office Coordinator (OC) stated that she was certain that a meeting of the IDG to review plans of care was held on 6/16/22. The OC confirmed that there was no documented evidence that she could locate or provide of the IDG review that occurred between 6/2/22 and 6/30/22.

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, contributing to patient and family counseling and education. 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 CONDITION was not met as evidenced by review of personnel records, clinical records, and interviews. The hospice failed to ensure that all core services including counseling services were provided directly by hospice employees [HCDT.2.I/L588]; and the hospice failed to ensure that the medical social worker (MSW) visits were performed as per the patient's plan of care [HCDT.9.I/L594]. This deficient practice negatively impacted the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions. This is a CMS CONDITION level finding.

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 standard was not met as evidenced by a review of personnel records and interviews. 1 of 1 (100%) personnel records reviewed for employees contracted or hired after 6/2/22 revealed that the hospice failed to ensure all core services, including counseling services were provided directly by hospice employees. Staff #1: The personnel record contained an "independent contractor agreement" e-signed by the Chaplain on 6/8/22 (effective as of 6/10/22). The agreement was not signed by the Administrator and was not fully executed. The Office Coordinator and the Human Resources Manager confirmed the finding during interview and a joint review of the record. This CONDITION was not met as evidenced by personnel record review and interviews. The agency failed to routinely provide substantially all core services directly by hospice employees, in a manner consistent with acceptable standards of practice, to include counseling services [HCDT.2.I/L588]. The agency failed to assemble an interdisciplinary group that included an individual qualified and competent to practice in the role of a pastoral or other counselor [HCPC.2.D/L541]. This deficient practice negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions. This is a CMS CONDITION level finding.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, and under the direction of a physician. This standard was not met as evidenced by a review of clinical records. 2 of 6 (33%) of clinical records reviewed revealed that the hospice did not ensure that the Medical Social Worker (MSW) visits were performed as per the patient's plan of care. Record #2 was reviewed and identified that the patient elected hospice care on 2/8/2022. The plan of care documented MSW visits to be performed 1-2 times per month. There were no MSW visits documented as completed during the month of June. Record #5 was reviewed and identified that the patient elected hospice care on 3/14/2022. The plan of care documented MSW visits to be performed 1-2 times per month. There were no MSW visits documented as completed during the month of June, The last documented MSW visit was completed on 5/19/22.

It is required that the hospice provides an orientation on the hospice philosophy to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by a review of personnel records and interviews. 1 of 1 (100%) of personnel records reviewed revealed the hospice did not ensure that for employees hired or contracted after 6/2/22, the agency provided training on the hospice philosophy prior to patient and family contact. Staff #1 was reviewed and identified the Chaplain's independent contractor agreement was dated 6/8/22 (effective as of 6/10/22) There was no documented evidence that the Chaplain received orientation to the hospice philosophy, including the needs and concerns of patients and families coping with a terminal illness. The Office Coordinator and the Human Resources manager confirmed during interview that there was no documented evidence of training that was provided to the chaplain related to the hospice philosophy or regarding the common needs and concerns of patients and families coping with a terminal illness prior to patient and family contact.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 4 (50%) records reviewed with the benefit of election dates after 6/2/22, revealed the hospice did not ensure that the patients received the "Patient Notification of Non-covered Items, Services, and Drugs." Record #1 was reviewed and identified that the patient elected hospice care on 6/18/22. There was no evidence that the document, "Patient Notification Non-Covered Items, Services, and Drugs" was provided as part of the hospice admission packet. Record #3 was reviewed and identified that the patient elected hospice care on 6/21/22. There was no evidence that the document, "Patient Notification Non-Covered Items, Services, and Drugs" was provided as part of the hospice admission packet. During an interview, the Office Coordinator confirmed the finding and stated that going forward she would ensure that all new start of care packets contain the CMS Hospice Election Statement Addendums.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 a review of clinical records and interviews. 1 of 2 (50%) clinical records reviewed associated with the 3rd benefit period recertification and any subsequent recertification period, revealed the hospice did not ensure that there was a timely face-to face encounter that occurred as required to recertify the patient's terminal illness.. Record #5 was reviewed and identified that the patient elected hospice care on 3/14/22. The record included a clinic visit note dated 5/23/22 which was obtained and placed in the patient's record by the Office Coordinator on 7/14/22. There was no documented evidence of a face-to-face encounter completed within 30 days prior to the start of the 7th benefit period effective on 7/12/22. During an interview, the Hospice Medical Director stated that he was unaware that a face-to-face encounter was required to occur within 30 calendar days prior to the start of the third and subsequent benefit periods as a condition of recertifying a patient's terminal illness.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. This standard was not met as evidenced by a review of clinical record and interview. 1 of 1 (100%) record reviewed for a patient receiving routine hospice care in a Skilled Nursing Facility (SNF) revealed the hospice failed to delineate which provider is responsible for care and services included in the plan of care. Record #1 was reviewed and identified that the patient elected hospice care on 6/18/22. The plan of care did not specify which provider was responsible for performing functions that are outlined in the plan of care. This finding was confirmed by the Office Coordinator during an interview and a joint review of the record.

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. This standard was not met as evidenced by review of the agency's patient handbook and interview. The agency's office coordinator and the DPCS stated that patients are provided with a POLST document that is included in a patient handbook given to all patients at the time of admission, to make their end of life wishes known. The agency's office coordinator and the DPCS stated that the patient handbook did not contain the individual's rights under State law as required by state guidelines for hospice agencies.

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 review of clinical records and interview. In 11 of 11 (100%) clinical records with start of care dates after 10/1/2020, there was no documentation to support that patients were notified of their right to receive information regarding the medications and services that were covered under the hospice benefit and those that were not, as required by the CMS Hospice Election Statement Addendum, effective October 1, 2020, "Patient Notification of Non-covered Items, Services, and Drugs." Patient ID# 61397 (SOC 12/17/2021; 2nd Benefit Period effective 3/17/22; DX: Cerebral Atherosclerosis) Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung) Patient ID# 40493 (SOC in 3rd Benefit Period 3/16/2022; 4th Benefit Period Effective 5/15/22. DX: CVA/Stroke) Patient ID# 20466 (SOC 6/24/2021; 5th Benefit Period Effective 4/20/2022; Died 5/10/2022. DX: Cerebral Atherosclerosis) Patient ID# 90390 (SOC in 3rd Benefit Period 2/9/2022. DX: Cerebral Atherosclerosis. SNF visit with LVN.) Patient ID# 89052 (SOC 1/7/2022; 2nd Benefit Period effective 4/7/2022. DX: Cerebral Atherosclerosis. Home visit with AIDE.) Patient ID# 84904 (SOC 1/23/2021; 7th Benefit Period effective 3/29/2022. Live DC to hospital 5/16/2022. DX: CA Prostate) Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition) Patient ID# 88054 (SOC 11/2/2021; 2nd Benefit Period effective 1/31/2022; Live DC for extended prognosis 4/6/2022. DX: Alcoholic Cirrhosis of the Liver) Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease) Patient ID# 48723 (SOC 4/24/2022. DX: Alzheimer’s. Home visit with MSW/Bereavement Coordinator) The DPCS was interviewed and stated that they were not aware that the "Patient Notification of Non-covered Items, Services, and Drugs" was to be provided with required verbiage as an addendum to the written Patient Bill of Rights, and confirmed that following patients did not receive information contained in the CMS Hospice Election Statement Addendum.

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 reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by a review of clinical records and interview. 4 of 4 (100%) clinical records reviewed revealed the hospice did note ensure an update of the comprehensive assessment by the IDG as frequently as the condition of the patient requires, but no less frequently than every 15 days. Patient ID# 61397 (SOC 12/17/2021; 2nd Benefit Period effective 3/17/22; DX: Cerebral Atherosclerosis). No visit was performed by an RN since recertification on 3/16/22. No RN comprehensive assessment was documented between 3/17/22 and 5/31/22. Patient ID# 90390 (SOC in 3rd Benefit Period 2/9/2022. DX: Cerebral Atherosclerosis. SNF visit with LVN.) No RN comprehensive assessment was documented between 2/10/22 and 3/6/22, greater than 21 days. Patient ID# 89052 (SOC 1/7/2022; 2nd Benefit Period effective 4/7/2022. DX: Cerebral Atherosclerosis. Home visit with AIDE.) No RN comprehensive assessment between 5/1 and 6/1/22, greater than 21 days. Patient ID# 40493 (SOC in 3rd Benefit Period 3/16/2022; 4th Benefit Period Effective 5/15/22. DX: CVA/Stroke) No RN visits were performed after recertification 5/7/22, greater than 21 days. No RN comprehensive assessment was documented between 5/8/22 and 6/1/22. The RN/Clinical Supervisor stated that it was his practice to visit patients to perform a comprehensive assessment prior to the subsequent benefit period if the patient was being visited by an LPN.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This CONDITION was not met as evidenced by a review of patient records and interview. The hospice failed as follows: the IDT in coordination with the physician did not prepare written plan of care for each patient [HCPC.18.I/L537] to provide coordination of care and to ensure continuous assessment of each patient’s and family's needs and implementation of the interdisciplinary plan of care. [HCPC.19.I/L540]; to ensure a pastor or other counselor was part of the interdisciplinary group [HCPC.2.D/L541]; . to ensure an individualized written plan of care had been to prepared for each patient based on the comprehensive assessment [HCPC..21.I/L545]; to ensure that all hospice care and services furnished to patients and their families followed an individualized written plan of care [HCPC.91.I/L543]; to develop plans of care which included interventions to manage pain and symptoms [HCPC.21.I/L546]; to ensure that written plans of care or individual physician orders specified the scope and frequency of services.[HCPC.21.L547]; to implement an interdisciplinary plan of care including all medications and treatments to meet the needs of the patient [HCPC.21.I/L549]; to ensure plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care [HCPC.21.I/L548]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality patient care in a safe environment This is a CMS CONDITION level finding.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of patient records and interview. In 3 of 11 (27%) records reviewed revealed the hospice did not ensure a written plan of care had been prepared for each patient's and family's specific needs based on the initial assessment. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung) Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition) Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease) The DPCS stated that the plan of care had not been established due to the patient’s short length of stay.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. 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 a review of patient records and interview. In 3 of 11 (27%) patient records reviewed the registered nurse failed to implement an interdisciplinary plan of care. There was no documented evidence that a written plan of care had been prepared for each patient's and family's specific needs based on the initial assessment. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung) Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition) Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease) The DPCS was interviewed on 6/1/2022 and confirmed the finding.

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 was not met as evidenced by clinical record review and interview. 100% of clinical records reviewed revealed the hospice did not ensure a pastor or other counselor was part of the interdisciplinary group. The agency's office coordinator stated that she spoke with human resources and confirmed that the position of spiritual counselor was vacant. The agency's owner/administrator/hospice medical director was interviewed on 6/1/2022 and confirmed that there was no employee serving in the role of spiritual counselor on the IDG.

It is required he hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by review of clinical records. 2 of 11 (18%) patient files reviewed revealed that nursing visits performed did not match the frequency of nursing visits included in the patient plan of care. Patient ID# 84904 (SOC 1/23/2021; 7th Benefit Period effective 3/29/2022. Live DC to hospital 5/16/2022. DX: CA Prostate): Skilled nursing visits are documented as to be performed twice each week per the plan of care. 1 missed visit each week, weeks of 3/22, 3/27, 4/3, 4/10, 4/17, 4/24, 5/1, and 5/8/22. Patient ID# 89052 (SOC 1/7/2022; 2nd Benefit Period effective 4/7/2022. DX: Cerebral Atherosclerosis. Home visit with AIDE.) Skilled nursing visits are documented as to be performed twice each week per the plan of care. 1 missed visit each week, weeks of 5/1, 5/8, 5/15, 5/22/22.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including the following: intervention to manage pain and symptoms, a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the plan of care, drugs, and treatment necessary to meet the needs of the patient, medical supplies and appliances necessary to meet the needs of the patient, includes the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by a review of clinical records and an interview. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure an individualized written plan of care had been prepared for each patient based on the comprehensive assessment. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung) Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition) Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease). The DPCS confirmed that there was no written plan of care documented for the following patients:

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 the intervention to manage pain and symptoms. This standard was not met as evidenced by a review of clinical records. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure plans of care included interventions for pain and symptom management. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung). There were no interventions documented by the IDG in order to palliate pain and end of life symptoms. Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition). There were no interventions documented by the IDG in order to palliate pain and end of life symptoms. Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease). There were no interventions documented by the IDG in order to palliate pain and end of life symptoms.

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 and related conditions, 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 a review of clinical records. 3 of 11 (27%) records reviewed revealed the hospice did not ensure the establishment of a written plan of care or individual physician orders specifying the scope and frequency of services. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung) Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition) Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease)

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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 8 of 8 (100%) records reviewed revealed, the plan of care did not include measurable outcomes that were written in such a way that could be anticipated from implementing and coordinating the plan of care. Patient ID# 61397 (SOC 12/17/2021; 2nd Benefit Period effective 3/17/22; DX: Cerebral Atherosclerosis). The written plan of care included the following non-measurable outcome: Problem: Neurological Intervention: Assess level of consciousness/orientation. Goal: Anxiety managed within comfort levels. Patient ID# 40493 (SOC in 3rd Benefit Period 3/16/2022; 4th Benefit Period Effective 5/15/22. DX: CVA/Stroke). The written plan of care included the following non-measurable outcomes: 1. Problem- Pain. Intervention - Assess for signs/symptoms managed within comfort levels. Goal-Pain. 2. Problem: Neurological. Intervention: Assess for signs/symptoms. Goal-Anxiety. Patient ID# 20466 (SOC 6/24/2021; 5th Benefit Period Effective 4/20/2022; Died 5/10/2022. DX: Cerebral Atherosclerosis). The written plan of care included the following non-measurable outcome: Problem: Nutrition Intervention: Assess for signs and/or symptoms of dysphagia and modify consistency of liquids as ordered. Goal. Dysphagia is managed within comfort levels. Patient ID# 90390 (SOC in 3rd Benefit Period 2/9/2022. DX: Cerebral Atherosclerosis. SNF visit with LVN.). The written plan of care included the following non-measurable outcome: Problem: Neurological. Intervention: Assess level of consciousness or orientation. Goal: Confusion managed within comfort levels. Patient ID# 89052 (SOC 1/7/2022; 2nd Benefit Period effective 4/7/2022. DX: Cerebral Atherosclerosis. Home visit with AIDE.). The written plan of care included the following non-measurable outcome: Problem: Gastrointestinal. Intervention: Reduce environmental stressors; auscultate for abdomen for bowel sounds. Goal: Incontinence is controlled as normally as possible. Patient ID# 84904 (SOC 1/23/2021; 7th Benefit Period effective 3/29/2022. Live DC to hospital 5/16/2022. DX: CA Prostate). The written plan of care included the following non-measurable outcome: Problem-Cardiovascular. Intervention: Elevate lower extremities. Goal: Cardiovascular. Patient ID# 88054 (SOC 11/2/2021; 2nd Benefit Period effective 1/31/2022; Live DC for extended prognosis 4/6/2022. DX: Alcoholic Cirrhosis of the Liver). The written plan of care included the following non-measurable outcome: Problem: Musculoskeletal. Intervention: Identify safety issues and educate on safety precautions to prevent fall and/or injury. Goal: Weakness managed within normal status as possible. Patient ID# 48723 (SOC 4/24/2022. DX: Alzheimer’s. Home visit with MSW/Bereavement Coordinator). The written plan of care included the following non-measurable outcome. Problem: Psychosocial. Intervention: Advocate and work with patient to ensure needs are communicated and patient has proper support. Goal: Patient will remain safe without any self-harm. Patient will report an increase in sense of control over her current situation. One problem was identified on the plan of care since 4/24/22. The DPCS was interviewed on 6/1/2022 and confirmed these findings.

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 and related conditions, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interview. 3 of 11 (27%) patient records reviewed revealed no documented evidence of the establishment of a written plan of care and no individual physician orders specifying drugs and treatments necessary to meet the needs of the patient. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung)-The record contained no physician admission orders and no plan of care. Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition)-The record contained no physician admission orders and no plan of care. Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease)-The record contained no physician admission orders and no plan of care. The DPCS confirmed this finding.

It is required that the hospice 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 review of the agency’s documented performance improvement projects (PIPs) and interview. Quarterly meeting minutes between 4th quarter 2019 and first quarter 2022 included documents outlining “Audits/Findings/Trends” and “Action Plans” for PIPs such as “The initial comprehensive assessment will be completed within the first 5 days following the election of the hospice benefit”. Columns labeled “Analysis” and “Sustainability” remained blank for each quarter for all PIPs identified with documented action plans. The agency’s DPCS who also serves as the QAPI Coordinator stated the agency did not document the level of improvement, if any, over time or whether performance goals were achieved or sustained over time.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by home visit observation and interview. In 2 of 3 (66%) home visit observations, hand decontamination was not performed in accordance with CDC guidelines. Patient ID# 89052 (SOC 1/7/2022; 2nd Benefit Period effective 4/7/2022. DX: Cerebral Atherosclerosis.) Board & Care visit with hospice aide (ID# 49464, date of hire 5/20/2021). Following hand washing, the aide was observed removing assessment tools from a nursing bag, assessed patient using each tool, handled the patient’s bed rail, bathing supplies, and retrieved linens from a congregate closet without sanitizing hands in between each action to prevent cross contamination between the patient and objects used in patient assessment and personal care. Patient ID# 90390 (SOC in 3rd Benefit Period 2/9/2022. DX: Cerebral Atherosclerosis.) SNF visit with LVN (ID# 38705, date of hire 8/12/2020). Following handwashing, the LVN removed assessment tools from a nursing bag, assessed patient using each tool, checked the patient’s skin from head to toe while touching intact skin and patient clothing without consistently sanitizing hands in between each action to prevent cross contamination between the patient and objects used in patient assessment. The DPCS confirmed that hand hygiene is expected to be performed by clinical staff after each action during physical assessments and personal care.

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 CONDITION was not met as evidenced by personnel record review and interviews. The hospice failed to ensure that all core services including nursing services, medical social services, and counseling services were provided directly by hospice employees. During interview, the owner/administrator/hospice medical director stated that the Medical Social Worker/Bereavement Coordinator was also the agency's spiritual counselor. The Medical Social Worker/Bereavement Coordinator stated that he has been the Chaplain for other hospice agencies. Personnel record review for MSW/Bereavement Coordinator ID# 46425, date of hire 11/19/2019 contained signed job descriptions for the positions of social worker and bereavement coordinator only. On day 3 of the site visit the office coordinator confirmed with human resources the position of spiritual counselor was "waiting to be filled." The administrator was interviewed on how long the core service of spiritual counselor had been vacant, but would only state "since our chaplain retired" and did not provide a date. The agency failed to routinely provide substantially all core services directly by hospice employees, in a manner consistent with acceptable standards of practice, to include counseling services [HCDT.2.I/L588]. The agency failed to assemble an interdisciplinary group that included an individual qualified and competent to practice in the role of a pastoral or other counselor [HCPC.2.D/L541]. This deficient practice negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions. This is a CMS CONDITION level finding.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by a review of clinical records and interview. In 6 of 11 (55%) patient files reviewed revealed aide visit frequencies were not consistent with the patient plan of care. Patient ID# 61397 (SOC 12/17/2021; 2nd Benefit Period effective 3/17/22; DX: Cerebral Atherosclerosis)-Aide Missed Visits -1 missed each week on weeks effective 5/1, 5/8, 5/15, 5/22, 5/29/22 Patient ID# 40493 (SOC in 3rd Benefit Period 3/16/2022; 4th Benefit Period Effective 5/15/22. DX: CVA/Stroke)-Aide missed visits-2 visits missed week of 5/22/22 Patient ID# 89052 (SOC 1/7/2022; 2nd Benefit Period effective 4/7/2022. DX: Cerebral Atherosclerosis. Home visit with AIDE.)-Aide-1 visit missed each week, weeks of 3/22, 3/27, 4/3, 4/10, 4/17, 4/24, 5/1, and 5/8/22 Patient ID# 88054 (SOC 11/2/2021; 2nd Benefit Period effective 1/31/2022; Live DC for extended prognosis 4/6/2022. DX: Alcoholic Cirrhosis of the Liver)-AIDE went 3 times/documented after DC date of 4/6/22-1 extra visit in week of 4/3/22 and 2 extra visits in week of 4/7/22 Patient ID# 48723 (SOC 4/24/2022. DX: Alzheimer’s. Home visit with MSW/Bereavement Coordinator)- Aide missed visits-2 visits missed weeks of 5/8, 5/15, and 5/22/22 The office coordinator stated that aides are not able to document visits unless orders are entered and visits are scheduled on the EMR calendar. The office coordinator stated that this had not been done for the patients with missed aide visit frequencies.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation; provision of care and services; fiscal operations; and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by interview with the owner/administrator/hospice medical director. The owner/administrator/hospice medical director revealed that he has been unsuccessful in hiring an administrator, spiritual counselor and volunteer coordinator for the agency. The owner/administrator/hospice medical director stated that he was a cardiologist with medical office/private practice and hospital responsibilities, as well as ownership of SNF and Board & Care facilities. The owner/administrator/hospice medical director agreed that he did not have the time for oversight of the day to day operations of the organization and needed to hire a qualified administrator to take over this role.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement; Responses to medications, symptom management, treatments, and services; Outcomes measure data elements per regulation; Physician certification and recertification of terminal illness as required; Any advance directives; Copies of inpatient discharge summary, as applicable; and Physician orders. This CONDITION was not met as evidenced by a review of patient records and interview. This CONDITION was not met as evidenced by a review of patient records and interview. The hospice failed as follows: to ensure that each patient’s record included the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes [HSIM.3.I/L672]; signed copies of the notice of patient rights in accordance with 418.52 and election the statement in accordance with 418.24 [HSIM.3.1/L673]; physician certification and recertification of terminal illness [HSIM.3.I/L676]; physician orders [HSIM.3.I/L678]; to provide hospice discharge summaries to receiving facilities when patients were transferred [HCDT.38.I/L682] and discharge summaries did not include documentation of the patient's treatments, symptoms and pain management, current plan of care and the patient's latest physician orders [HCDT.40.I/L684]. The cumulative effect of these systemic issues compromised the hospice's ability to provide quality patient care in a safe environment. This is a CMS CONDITION Level finding

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments and clinical notes including care and services provided. This standard was not met as evidenced by review of patient records and interview. 3 of 11 (27%) records reviewed revealed the hospice did not ensure each patient's record contained an initial plan of care. Patient ID# 80429; ID# 12874; and ID# 18491 4 of 4 (100%) applicable records reviewed revealed the hospice did not ensure an updated comprehensive assessment was completed and contained within the record at minimum every 15 days, up to 21 days under the public health emergency waiver. Patient ID# 61397; ID# 40493; ID# 90390 and ID# 89052.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by review of clinical records and interview. The hospice did not ensure that patients received the CMS Hospice Election Statement Addendum. Patient ID# 61397 (SOC 12/17/2021; 2nd Benefit Period effective 3/17/22; DX: Cerebral Atherosclerosis) Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung) Patient ID# 40493 (SOC in 3rd Benefit Period 3/16/2022; 4th Benefit Period Effective 5/15/22. DX: CVA/Stroke) Patient ID# 20466 (SOC 6/24/2021; 5th Benefit Period Effective 4/20/2022; Died 5/10/2022. DX: Cerebral Atherosclerosis) Patient ID# 90390 (SOC in 3rd Benefit Period 2/9/2022. DX: Cerebral Atherosclerosis. SNF visit with LVN.) Patient ID# 89052 (SOC 1/7/2022; 2nd Benefit Period effective 4/7/2022. DX: Cerebral Atherosclerosis. Home visit with AIDE.) Patient ID# 84904 (SOC 1/23/2021; 7th Benefit Period effective 3/29/2022. Live DC to hospital 5/16/2022. DX: CA Prostate) Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition) Patient ID# 88054 (SOC 11/2/2021; 2nd Benefit Period effective 1/31/2022; Live DC for extended prognosis 4/6/2022. DX: Alcoholic Cirrhosis of the Liver) Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease) Patient ID# 48723 (SOC 4/24/2022. DX: Alzheimer’s. Home visit with MSW/Bereavement Coordinator) The DPCS was interviewed and stated that they were not aware that the "Patient Notification of Non-covered Items, Services, and Drugs" was to be provided with required verbiage as an addendum to the election statement.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by review of clinical records and interview. 7 of 7 (100%) clinical records reviewed revealed the hospice did not ensure recertification of the terminal illness (CTI) was written and signed by the hospice medical director or physician-designee. Patient ID# 61397 (SOC 12/17/2021; 2nd Benefit Period (BP) effective 3/17/22; DX: Cerebral Atherosclerosis)- Verbal CTI 3/16/22 but no written CTI narrative for the 2nd BP Patient ID# 40493 (SOC in 3rd Benefit Period 3/16/2022; 4th Benefit Period Effective 5/15/22. DX: CVA/Stroke)- Verbal CTI only; no written CTI narrative for the 4th BP Patient ID# 20466 (SOC 6/24/2021; 5th Benefit Period Effective 4/20/2022; Died 5/10/2022. DX: Cerebral Atherosclerosis) - Verbal CTI only; no written CTI narrative for the 5th BP Patient ID# 90390 (SOC in 3rd Benefit Period 2/9/2022. DX: Cerebral Atherosclerosis. SNF visit with LVN.)-Verbal CTIs only; no written CTI narratives for the 3rd or 4th BPs Patient ID# 89052 (SOC 1/7/2022; 2nd Benefit Period effective 4/7/2022. DX: Cerebral Atherosclerosis. Home visit with AIDE.)-Verbal CTI only; no written CTI narrative for the 2nd BP Patient ID# 84904 (SOC 1/23/2021; 7th Benefit Period effective 3/29/2022. Live DC to hospital 5/16/2022. DX: CA Prostate)-Verbal CTI only; no written CTI narrative for the 7th BP Patient ID# 88054 (SOC 11/2/2021; 2nd Benefit Period effective 1/31/2022; Live DC for extended prognosis 4/6/2022. DX: Alcoholic Cirrhosis of the Liver)-No verbal and no written CTI narrative for the 2nd BP The DPCS stated that a clinical supervisor/RN was “working on” documenting narrative clinical content on paper versions of CTIs to present to the owner/administrator/hospice medical director to sign, but confirmed that the records reviewed did not include written recertification CTI documents.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at minimum physician orders. This standard was not met as evidenced by review of patient records and interview. 3 of 11 (27%) records reviewed revealed the hospice did not ensure clinical records contained physician's orders and written plans of care. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung) Patient ID# 12874 (SOC 5/20/2022; Died 5/20/2022. DX: Unspecified Severe Protein-Calorie Malnutrition) Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease) The DPCS confirmed this finding.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) discharge/transfer records, the hospice failed to forward the receiving facility a copy of the hospice discharge (DC) summary and did not provide contents of the patient's record. Patient ID# 84904 (SOC 1/23/2021; 7th Benefit Period effective 3/29/2022. Live DC to hospital 5/16/2022. DX: CA Prostate)- Transfer to hospital-no DC summary written; No documentation that DC/transfer documents sent to receiving hospital. Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease)-Transfer to hospital-no DC summary written; No documentation that DC/transfer documents sent to receiving hospital. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung)-Transfer to previous hospice-no DC summary written; No documentation that DC/transfer documents sent to receiving hospice. The office coordinator confirmed that no documents were sent to any entities following a live patient discharge or transfer.

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 a review of clinical records. 4 of 4 (100%) discharged records reviewed revealed the hospice did not ensure discharge summaries were written which included all required elements. Patient ID# 84904 (SOC 1/23/2021; 7th Benefit Period effective 3/29/2022. Live DC to hospital 5/16/2022. DX: CA Prostate)- Transfer to hospital-no DC summary written which included a summary of the patient's 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 post-discharge continuity of care. Patient ID# 18491 (SOC in 8th Benefit Period 12/22/2021. Live DC to hospital 1/2/2022; DX: Cerebrovascular Disease)-Transfer to hospital-no DC summary written. Patient ID# 80429 (SOC 12/19/2021; Live DC/Transfer to another hospice 12/22/2021. DX: CA Lung)-Transfer to previous hospice-no DC summary written. Patient ID# 88054 (SOC 11/2/2021; 2nd Benefit Period effective 1/31/2022; Live DC for extended prognosis 4/6/2022. DX: Alcoholic Cirrhosis of the Liver)-No DC summary written.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by review of patient records and interview. In 3 of 3 records (100%) reviewed of patient's residing in a SNF, there was no documented evidence of a hospice plan of care that specified which provider is responsible for performing functions outlined in the patient's plan of care. During a home visit observation with an LVN in a SNF with Patient ID# 90390 (SOC in 3rd Benefit Period 2/9/2022. DX: Cerebral Atherosclerosis, the LVN confirmed that the written plan of care did not specify which provider was responsible for functions outlined in the plan of care. The facility DON confirmed receipt of the hospice agency's plan of care but stated that the plan did not specify which provider was responsible for performing functions that are outlined in the plan of care. Patient ID# 61397 (SOC 12/17/2021; 2nd Benefit Period effective 3/17/22; DX: Cerebral Atherosclerosis) Patient ID# 40493 (SOC in 3rd Benefit Period 3/16/2022; 4th Benefit Period Effective 5/15/22. DX: CVA/Stroke) Patient ID# 90390 (SOC in 3rd Benefit Period 2/9/2022. DX: Cerebral Atherosclerosis. SNF visit with LVN.)