Every finding on record at Wellcare Hospice LLC

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 clinical record review and interview. 6 of 20 (30%) clinical records reviewed revealed that the agency did not ensure that the Interdisciplinary Group, specifically the Social Worker and the Chaplain, completed their initial assessments within five days after election to hospice care. Clinical Record 1: The patient elected the hospice benefit on 4/28/2023. The initial Social Worker visit was documented in the Medical Social Worker Visit Note/Hospice Initial Assessment on 5/5/2023, which was on the seventh day after the patient was admitted to hospice. There was no documentation in the visit note addressing why the initial visit was performed outside of the regulatory five-day window. In the Interdisciplinary Group Meeting dated 5/5/2023, the Social Worker's note indicated that the initial assessment would be completed on 5/5/2023 after IDT. "Pt/Family Identified Goals: LMSW to complete initial assessment 5/5 after IDT. " No explanation was provided as to why the initial visit was delayed outside the five-day window. Clinical Record 9: The patient elected the hospice benefit on 2/14/2023. The initial Social Worker visit was documented in the Medical Social Worker Visit Note/Hospice Initial Assessment on 2/20/2023, which was on the sixth day after the patient was admitted to hospice. There was no documentation in the visit note addressing why the initial visit was performed outside of the regulatory five-day window. In the Interdisciplinary Group Meeting dated 2/24/2023, the Social Worker's note did not indicate why there was a delay in the initial Social Worker assessment. Clinical Record 18: The patient elected the hospice benefit on 6/29/2022. The initial Social Worker visit was done on 7/6/2022, and the initial Chaplain visit was performed on 7/8/2022. The Chaplain documented in a communication note dated 7/8/2022 that an attempt was made to contact the patient's daughter, but the Chaplain had to leave a voice for her to call to complete the spiritual assessment. There was no documentation in the Social Worker's Initial Assessment on 7/6/2022 or the Chaplain's Initial Evaluation on 7/8/2022 as to why the initial assessments were delayed to 7 and 9 days post-admission. Clinical Record 17: The patient elected the hospice benefit on 12/22/2022. The initial Social Worker Assessment was not completed until 6 days after admission on 12/28/2022. The Chaplain's Initial Evaluation was performed on 12/30/22, 8 days after admission. There was no documentation as to why the initial visits were delayed past the initial 5 day timeframe. Clinical Record 5: The patient elected the hospice benefit on 7/14/2023. There had been no Social Worker Initial Assessment as of 7/25/2023, which was 11 days post-admission. There was no communication note entered documenting any reason for the delay. The RN Initial Assessment narrative read, "Nursing 2x week or more depending on pain management, Aide 3x week for showers, Chaplain - eval; MSW - OOHDNR signed and sent to 'SW', coordination of care." There were discipline orders for Nursing, Chaplain, and Aide visits in the initial Plan of Care, but Social Worker visits were not addressed. Clinical Record 15: The patient elected the hospice benefit on 1/12/2023. The Chaplain's Initial Visit was 2/20/2023. There was no documentation within the Chaplain's note about why the initial visit was delayed. There was no Communication Note from 1/12/23 to 2/12/23, no IDT note for IDT meetings held on 1/13/23 or 1/27/23 that explain the delay in the initial visit. There was an RN Prep Note Communication Note 1/25/23 that stated Chaplain services were accepted. Personnel Record 2: In an interview and joint record review on 7/26/2023 and 7/27/2023 with the Regional Director of Clinical Support and Education, she confirmed that for the records listed, the IDG did not make their visits within the five-day window after admission to hospice.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes the use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, characteristics of the pain, including location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping), and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 20 (5%) clinical records reviewed revealed that the agency did not ensure that patients received pain assessments as a part of updated comprehensive pain assessments. Document 1: The agency policy, "Pain Assessment" (Policy No. 1-018), with the revised date of April 2019, included, "When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient's condition...When the ...clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible...pain intensity, pain location, pain quality, pain onset, alleviating and aggravating factors, present pain management regimen and effectiveness...If a patient is unable to communicate pain using the rating scale...the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment." Clinical Record 11: The patient elected the hospice benefit on 4/10/2023. The RN Initial Assessment on 4/12/2023 documented a comprehensive pain assessment. The nurse documented the patient was receiving scheduled Morphine on 4/13/2023, and regular Morphine use was documented until the day before the patient's death on 4/16/2023. The initial RN note was the only comprehensive pain assessment included in the clinical record. There was no documented evidence of any updated comprehensive pain assessments throughout the patient's hospice GIP stay in response to the patient's pain and the administration of narcotic analgesics. The RN 4/13/23 Narrative Note dated 4/13/2023 documented pulse, respiratory rate, and oxygen saturations. No systems assessment (cardiovascular, respiratory, gastrointestinal, etc.), pain screening, or comprehensive pain assessment were documented. The nurse only documented, "Patient appears to be comfortable, will continue to monitor for symptom management and comfort." On 4/14/2023, the RN documented pulse, respiratory rate, and oxygen saturations, but no further body system assessment was performed. The narrative only included “Actively dying coordination of care with HMTW. Morphine is being given q2 hours due to air hunger and symptom management. Reviewed POC and GIP criteria, family to discuss plans for DC if/when necessary. Will continue to monitor for symptom management and comfort.” On 4/15/23, the only documentation was the patient's pulse, respiratory rate, and oxygen saturation. There was no update to the patient's pain screening or pain assessment data. In the narrative, the nurse documented, “Continues to be on GIP level of care, patient is actively dying. Reviewed plan for DC to final placement during transitioning. Wife is at bedside however son is MPOA. Will review POC with hospital, meds continue to be given around the clock.” The last documented note in the patient's chart was by the RN on 4/16/23. The nurse documented the patient's respiratory rate and oxygen saturation. There was no documentation at all addressing the patient's assessed level of comfort. Personnel Record 2: In a joint record review and interview with the Regional Director of Clinical Support and Education on 7/26/2023 and 7/27/2023, she confirmed that the nurse did not document pain assessments on the patient.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 20 (5%) clinical records reviewed revealed the agency did not ensure that the comprehensive assessment and updated assessments included the patient's list of current medications. Document 1: The agency's policy, "Medication Profile" (Policy No. 2-004), with the revised date of April 2019, reads, "Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record." "Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date, and time of administration... Clinical Record 11: The patient elected the hospice benefit on 4/10/2023 to the General Inpatient Level of Care. In the Registered Nurse's Initial/Comprehensive Admission Assessment performed on 4/12/203, the nurse documented in the narrative that Robinol was added to the patient’s medication regimen due to increased terminal secretions, The nurse made no note as to what other medications the patient was receiving at the time of admission. Then in the Skilled Nursing Visit on 4/13/2023, the nurse documented that the patient was receiving morphine every 2 hours scheduled and that Acetaminophen suppositories were added to the patient’s medications to address his low-grade temperature. During every nursing visit from 4/12/2023 to 4/16/2023, the nurse documented that the patient was on oxygen. The agency failed to ensure that there was a medication profile for this patient that contained the medications that the patient was receiving while in hospice care. The Initial Plan of Care for the patient for dates 4/10/2023 - 7/8/2023 included no medications. The Medication Profile was blank, and no verbal or written orders were documented for any medications while the patient was in hospice care from 4/10/2023 to their death on 4/17/2023. The medications, their route of delivery, the dose, and the frequency of dosing were not included in the patient’s comprehensive assessment, any updates, or on the patient’s plan of care. Personnel Record 2: In a joint record review and interview on 7/25/2023 with the Regional Director of Clinical Support and Education, she confirmed that the patient's clinical record did not contain orders for the medications that the nurse documented the patient was receiving while on hospice care.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 20 (5%) clinical records reviewed revealed that the agency did not ensure that an initial bereavement risk assessment was performed upon admission to hospice. Clinical Record 2: The patient elected the hospice benefit on 10/25/2022. Chaplain services were declined at admission. The RN's Hospice Initial Assessment on 10/25/2022 and the Social Worker's Initial Assessment on 10/27/2022 did not include an initial bereavement risk assessment. The Nurse's and the Social Worker's notes from 11/4/2022 or 11/17/2022 did not address an initial bereavement risk assessment. The patient's medical record includes a daughter as his primary caregiver and Power of Attorney. Personnel Record 2: A joint record review and interview on 7/27/2023 with the Regional Director of Clinical Support and Education confirmed that in record 2, there was no initial bereavement risk assessment documented.

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 IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review and interview, the hospice failed as follows: to include on the POC patient and family goals and interventions based on problems identified in the comprehensive assessment [418.56(c)/L545]; to follow the visit frequency necessary to meet the patient and family specific needs according to the individualized care plan [418.56(c)(2)/L547]; to provide hospice care and services consistent with the individualized plans of care according to the patient's needs [418.56(b)/L543]; to provide an ongoing assessment of the patient and family needs, and to implement the plan of care [418.56(a)/L540]; to ensure the comprehensive assessment and updated assessments include the current list of medications [418.54(c )/L530; and to perform pain assessments as a part of updated comprehensive pain assessments [418.54(c)/L524. The cumulative effect of these deficiencies could negatively impact the organization's ability to provide safe and effective quality patient care services.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. 1 of 20 (5%) clinical records reviewed revealed that the agency did not ensure that the registered nurse provided a thorough, ongoing assessment of the patient and family needs and to implement the patient's plan of care. Document 1: The agency's policy, "The Plan of Care" (Policy No. 9-017) with the revised date of April 2019, includes that, "The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments ...The plan will focus on identified problems, goals, and interventions...This plan of care must be initiated at the start of care...The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care ...orders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care ...The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief... The written plan of care will contain, but not be limited to...placement at the appropriate level of care ...individualized interventions to assist with end-of-life care...statement of treatment goals...drugs and treatments." Clinical Record 11: The patient elected the hospice benefit on 4/10/2023 and was admitted to the General Inpatient Level of Care, where he passed on 4/17/2023. The Registered Nurse (RN) documented in the Hospice Initial Assessment dated 4/12/23 the need to add the medication Robinol to address the patient’s symptom of terminal secretions. Then on 4/13/2023, the RN documented the patient had labored breathing and required morphine every 2 hours. Additionally, it was noted that the patient was experiencing a low-grade fever, and Acetaminophen suppositories were added to assist in the patient’s comfort to lower his temperature. The RN documented on 4/14/2023 that Morphine continued to be given every 2 hours. Documented by the hospice nurse on 4/15/2023 was that the patient’s respiratory effort continued to be labored and that he required medications to be administered around the clock to manage his symptoms. And lastly, the final documentation in the clinical record from the RN was on 4/16/23 and only included that the patient continued to have labored respiratory effort. After the Hospice Initial Assessment on 4/12/2023, the RN did not document in the daily visit notes any comprehensive assessment of body systems including cardiopulmonary assessment or respiratory assessment to include breath sounds or the effectiveness of the interventions documented such as Robinol for terminal secretions, the effectiveness of the Morphine or oxygen in decreasing the patient’s work of breathing, or any pain assessments. The nurse did not ensure documentation of the family’s needs during the time the patient was on hospice in the General Inpatient Level of Care or what interventions required that the patient remained at that GIP level of care, such as frequent skilled assessment by a nurse for the patient’s comfort or for intravenous medication administration. The Initial Plan of Care for the patient for the dates 4/10/2023 - 7/8/2023 included no medications, oxygen, or Foley catheter orders. The only identified problems, interventions, and goals for the patient were limited to the RN’s identification of the problem of Pain/Pain Management with the interventions to administer analgesics as prescribed by the physician. The only physical goal listed was that the patient would be pain free. While the nurse notes documented that the patient received Morphine, Robinul, Acetaminophen suppositories, and oxygen for comfort while in General Inpatient care, the nurse did not ensure implementation of the plan of care as it did not reflect these interventions nor did the Plan of Care reflect ongoing assessment of the patient's and family's needs, and there were no interventions or goals to address the General Inpatient level of care. The patient's deteriorating respiratory status was not reflected in the patient's Plan of Care nor was the patient's imminent death. The interventions, specifically the comfort medications utilized to keep the patient comfortable, were not included in the patient's Plan of Care. Personnel Record 2: The Regional Director of Clinical Support and Education confirmed that the registered nurse did not ensure ongoing assessments, documentation of the medications and orders, or the appropriate problems, interventions, or goals were implemented after a joint record review and interview on 7/26/2023.

Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 20 (5%) clinical records reviewed revealed that the agency did not ensure that the hospice care and services provided followed the patient's individualized plan of care according to the patients' needs. Clinical Record 11: The patient elected the hospice benefit on 4/10/2023 and was admitted to the General Inpatient level of care, where he passed on 4/17/2023. During the patient's hospice stay, the nurse documented in visit notes dated 4/12/2023, 4/13/2023, 4/14/2023, 4/15/2023, and 4/16/2023 assessments of a 16Fr Foley catheter and oxygen use, Additionally, the nurse referred in narrative notes for the dates listed above, the use of the following medications: Morphine, Robinul, and Acetaminophen suppositories. The Initial plan of care for the patient and subsequent physician orders for dates 4/10/2023 - 7/8/2023 included no medications, oxygen, or Foley catheter orders. The identified problems, interventions, and goals for the patient were limited to pain and grief. The patient died while on the GIP level of care. The plan of care did not include identified problems, goals, or interventions to address the GIP level of care, symptoms of respiratory distress with labored respirations and oxygen use, terminal secretions, or the patient's impending death, Document 1: The agency's policy, "The Plan of Care" (Policy No. 9-017) with the revised date of April 2019, includes that, "The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments ...The plan will focus on identified problems, goals, and interventions...This plan of care must be initiated at the start of care...The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care ...orders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care ...The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief... The written plan of care will contain, but not be limited to...placement at the appropriate level of care ...individualized interventions to assist with end-of-life care...statement of treatment goals...drugs and treatments." Personnel Record 2: The Regional Director of Clinical Support and Education confirmed that the patient's Plan of Care in the clinical record did not include the patient's medications, orders for the use of oxygen to include liter flow and delivery method, the patient's Foley catheter, or the appropriate problems, interventions, or goals were implemented after a joint record review and interview on 7/26/2023.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 3 of 20 (15%) clinical records reviewed revealed that the agency did not ensure that the patients' plans of care were updated to reflect new problem identification, interventions, or goals based on updated assessment data. Document 1: The agency's policy, "The Plan of Care" (Policy No. 9-017) with the revised date of April 2019 includes that, "The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments ...The plan will focus on identified problems, goals, and interventions...This plan of care must be initiated at the start of care...The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care ...orders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care ...The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief... The written plan of care will contain, but not be limited to...placement at the appropriate level of care ...individualized interventions to assist with end-of-life care...statement of treatment goals...drugs and treatments." Clinical Record 11: The patient elected the hospice benefit on 4/10/2023 and was admitted to the General Inpatient Level of Care, where he passed on 4/17/2023. The Registered Nurse's Hospice Initial Assessment dated 4/12/2023 documented that the patient was being assessed and admitted to the General Inpatient level of care via the hospice's contract with the hospital. During the assessment, the nurse documented that the patient was tachypneic with a respiratory rate of 22 and noted that the patient's respirations were labored. Additionally, the patient had an oxygen saturation of 73% while on oxygen. Lastly, the nurse documented that the patient had a 16Fr Foley catheter in place for urine drainage. The nurse's narrative described the patient as non-verbal and comatose with terminal secretions requiring the addition of the medication Robinol. A comprehensive pain assessment was completed using the FLACC scale with a score of 0 documented. It was noted that the patient was started on a scheduled and additional opioid as needed for analgesia as of 4/10/2023. The nurse noted that there were symptoms of imminent death as manifested by abnormal breathing pattern, cyanosis, and the patient being non-responsive. The initial Plan of Care for the dates 4/10/2023 to 7/8/2023 listed pain/pain management as an identified problem. The intervention for this problem was to administer analgesics as prescribed by the doctor to relieve the patient's pain. However, the initial Plan of Care did not identify any problems, interventions, or goals related to the General Inpatient level of care, terminal secretions, tachypnea, labored respiration, or oxygen use. Further, the patient's imminent death was not identified. And finally, the initial Plan of Care included no medications, no oxygen (no liter flow or delivery method), and no order or problem identified for the patient's Foley catheter. There were no additional physician orders entered or Plan of Care updates during the patient's hospice stay that included medications, oxygen, the Foley catheter, or any updated problems, interventions, or goals. Personnel Record 2: The Regional Director of Clinical Support and Education reviewed the clinical record and was interviewed on 7/26/2023. She confirmed that the clinical record did not contain medication orders or identified problems based on findings from the nurses comprehensive assessment for respiratory distress, oxygen use, Foley catheter, or imminent death. Clinical Record 4: The patient elected the hospice benefit on 4/17/2023. On 6/9/2023, the nurse documented a comprehensive pain assessment with a score of 7 due to a right lateral foot wound. A new order was received and documented dated 6/9/2023 for Tramadol 50mg every 6 hours as needed for pain. The patient was admitted on 4/17/2023 with Naproxen 250mg by mouth twice daily for generalized pain. On admission, there was an identified problem of pain management. This problem, with its interventions and goals, was discontinued on 4/21/2023. The updates to the Initial Plan of Care for the dates 4/17/2023 to 7/15/2023 and the Recertification Plan of Care for the dates 7/16/23 to 10/13/23 contained no update to the identified problems, interventions, or goals to address pain. The patient continued on the same dose of Naproxen and had PRN Tramadol added to the pain regimen. Clinical Record 8: The patient elected the hospice benefit on 7/14/2023. On admission, the nurse documented a FLACC score of 5 due to chronic right knee pain intermittently daily. Additionally, the nurse noted, "Currently experiencing an acute infection of the right lower extremity...localized to right knee with open site on right lateral knee. " The patient's list of medication orders included Methadone 10mg/ml: 5mg every 12 hours for pain (7/14/2023) and Cephalexin 500mg every 12 hours for 10 days (7/14/23 - 7/23/23). The patient's Initial plan of care for the dates of 7/14/23 to 10/11/23 contained no identified problems, interventions, or goals related to the patient's pain, use of scheduled Methadone, or identification of infection with antibiotic treatment. The first Interdisciplinary Group Meeting review of the patient was scheduled to occur on Friday, 7/28/23. Personnel Record 2: A joint record review and interview on 7/26/2023 and 7/27/2023 with the Regional Director of Clinical Support and Education confirmed that the Plans of Care were not appropriately updated to reflect new information obtained in the updated comprehensive assessments

It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. 1 of 20 (5%) clinical records reviewed revealed the agency did not ensure that the agency followed the visit frequency necessary to meet the patient and family needs in accordance with the individualized care plan Clinical Record 9: The patient elected the hospice benefit on 2/14/2023. The plan of care included a physician order for skilled nursing visits twice a week with the effective dates of 4/20/2023 to 5/14/2023. For the week beginning 4/23/2023, only one nursing visit was performed on 4/24/2023. There was no documentation explaining the missed visits. Personnel Record 2: In a joint record review on 7/26/2023 with the Regional Director of Clinical Support and Education, she agreed that there was one nursing visit missing for the patient for the week of 4/23/2023 according to the frequency orders.

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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 2 of 18 (11%) applicable clinical records of patients receiving hospice aide visits revealed the hospice did not ensure aides reported patient changes related to the plan of care to the Registered Nurse. Clinical Record 18: The patient elected the hospice benefit on 6/29/2022. The patient's chart contained a physician's order dated 12/26/2022 for Hospice Aide services twice a week (12/26/2022 to 1/7/2023). On 12/26/2022 and 1/2/2023 the hospice aide documented "facility provided care" in the aide visit note for a missed visit. The aide did not document that facility staff or the hospice RN were notified about the missed visits. Clinical Record 2: The patient elected the hospice benefit on 10/25/22. The patient's chart reflected a physician's order dated 6/22/2023 for Hospice Aide visits three times a week (6/22/23 - 8/19/23). The Aide Visit Note on 6/28/2023 documented that the patient refused the shower. However, the Aide did not document that the facility staff or the hospice RN was notified of the refusal. Personnel Record 2: In a joint record review with the Regional Director of Clinical Support and Education on 7/25/2023 and 7/27/2023, she agreed that there was no documentation in the patient's medical record that the Hospice Aide communicated to the Hospice RN that Hospice Aide Care Plan was not followed and not all Aide services were provided for Clinical Records 2 and 18.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) applicable clinical records to a Medicare/Medicaid-certified facility revealed that the agency did not ensure that the discharge summary was forwarded to the receiving facility. Document 1: The agency policy "Discharge from Hospice Program" (Policy No. 1-025) with the revised date of April 2019 stated, "When a patient is discharged, transferred, or referred to another organization, relevant information will include: reason for transfer or discharge, physical and psychosocial status at the time of transfer or discharge, including specific medical, psychosocial or other problems requiring interventions or follow-up, summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services, a copy of the current plan of care ...latest physician orders...continuing symptom management needs, e.g. pain, nausea, dyspnea..." Further, the policy read that the "documentation will be filed in the clinical record. Information will be documented on a discharge/transfer form ..." Clinical Record 9: The patient elected the hospice benefit on 2/14/2023. The patient's family chose to revoke the hospice benefit on 5/15/2023 after the patient experienced a fall with injury and was admitted to the hospital. There was no documentation that the discharge summary was sent to the hospital where the patient was admitted for care. Clinical Record 18: The patient elected the hospice benefit on 6/29/2022. The patient's family chose to sign a transfer document on 1/10/2023 to transfer to another hospice. There was no documentation that the discharge summary was sent to the hospice where the patient was transferred. Personnel Record 2: In a joint interview on 7/26/2023 with both the Regional Director of Clinical Support and Education and the agency Administrator, they confirmed that there was no documentation that the discharge summary of either patient was forwarded to the receiving hospital or hospice.

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, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed revealed that the hospice did not ensure that the discharge summary included the required information to facilitate continuity of care. Clinical Record 9: The patient elected the hospice benefit on 2/14/2023. On 5/15/2023, the patient's family elected to revoke the hospice benefit to have the patient admitted to the hospital after a fall. The discharge summary listed the patient's medications at the time of discharge but did not include a summary of the patient's stay, current plan of care, latest physician orders, or symptom management, which for this patient included the management of edema, wounds, and symptoms of anxiety/restlessness. Personnel Record 2: In a joint record review with the Regional Director of Clinical Support on 7/26/2023, she confirmed that while the discharge summary for the patient did contain the list of medications for the patient, the Plan of Care, physician orders, and a complete summary of the patient's hospice stay - including symptom management was not documented on the discharge form.

It is required that the hospice has written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The policies and procedures address the circumstances under which controlled drugs are disposed of (e.g., the patient’s death, a change in drug regimen, etc.) and the method to be used in accordance with the state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 2 (50%) applicable that the hospice nurse pronounced the patient's death revealed the agency did not follow the agency’s policy regarding the documentation of drug disposal at the time of the patient’s death that included the medication, dosage form, dose, and amount of the medication that was disposed of, and a witness of the medication destruction. The agency's policy, "Home Use and Disposal of Controlled Substances" (Policy No. 2-008), with the revised date of November 2020, stated, “In the event that a hospice patient no longer has a need for a controlled substance, a hospice nurse ...of a qualified hospice program, acting within the scope of employment, may handle any controlled substance that was lawfully dispensed to the person receiving care for the purpose of disposal of the controlled substance...the disposal occurs after the death of the patient ...If the family requests the hospice to dispose of the controlled substance, the hospice nurse ...will dispose of the drug in the home and will document in a clinical note the following: the type of controlled substances, dosage, dosage form, route of administration, quantity disposed of, time, date and manner of disposal, who witnessed the disposal." The patient elected the hospice benefit on 1/4/2023. The hospice nurse pronounced the patient on 1/7/2023, and the nurse documented the death in the Time of Death Note. The nurse documented, "Disposal of controlled medications: RN disposal of drugs. Controlled Substance Disposal Details: date 1/7/23 time 1930 manner in which disposed baggie with dishwashing liquid." The nurse did not document what medications were disposed of, the form/route of the medication, the amount of each medication, or who witnessed the disposal of the medications. In an interview with the Regional Director of Clinical Support and Education on 7/26/2023, she confirmed that there was no documentation in the patient's medical record of what medications or the amount of medications disposed of and that there was no documentation of a witness to the drug disposal. The agency's policy, "Home Use and Disposal of Controlled Substances" (Policy No. 2-008), with the revised date of November 2020, stated, "The hospice nurse ... attending the death of a hospice patient will inform the family/caregiver of their responsibility to dispose of all the patient's prescribed medications and will document this instruction in a clinical note. If the family/caregiver requests assistance with the disposal, the hospice employee will observe and provide verbal assistance as the family/caregiver properly disposes of the prescribed medications. The disposal will be documented in a clinical note. In the event that a hospice patient no longer has a need for a controlled substance, a hospice nurse ...of a qualified hospice program, acting within the scope of employment, may handle any controlled substance that was lawfully dispensed to the person receiving care for the purpose of disposal of the controlled substance...the disposal occurs after the death of the patient ...If the family requests the hospice to dispose of the controlled substance, the hospice nurse ...will dispose of the drug in the home and will document in a clinical note the following: the type of controlled substances, dosage, dosage form, route of administration, quantity disposed of, time, date and manner of disposal, who witnessed the disposal." The patient elected the hospice benefit on 1/4/2023. The hospice nurse pronounced the patient on 1/7/2023, and the nurse documented the death in the Time of Death Note. The nurse documented, "Disposal of controlled medications: RN disposal of drugs. Controlled Substance Disposal Details: date 1/7/23 time 1930 manner in which disposed baggie with dishwashing liquid." The nurse did not document what medications were disposed of, the form/route of the medication, the amount of each medication, or who witnessed the disposal of the medications. In an interview with the Regional Director of Clinical Support and Education on 7/26/2023, she confirmed that there was no documentation in the patient's medical record of what medications or the amount of medications disposed of and that there was no documentation of a witness to the drug disposal.

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 IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of records, observation, and interviews which revealed the agency failed to ensure that the designated RN provided coordination of care to ensure continuous assessment of the patient's needs and implemented the IDG plan of care [HCPC.19.I/L540]; failed to ensure that the care and services provided to patients followed the plan of care [HCPC.19.I/L543]; failed to ensure the plan of care included all services necessary for management of the terminal illness and related condition [HCPC.21.I/L545]; failed to ensure that the Interdisciplinary Group (IDG) reviewed, revised, and documented the plan of care no less frequently than every 15 calendar days [HCPC.22.I/L552]; and failed to ensure the patients plan of care was updated to include information from the patient’s updated comprehensive assessment [HCPC.22.I/L553]. The cumulative effect of these systemic problems resulted in the hospice's inability to ensure the provision of quality health care in a safe environment. Record 1: The patient’s date of election was 5/23/2022 with a primary diagnosis of chronic diastolic (congestive) heart failure. The RN SOC (start of care) visit on 5/23/2022 identified BLE wounds, foley catheter in place. The RN (registered nurse) routine visit on 5/25/2022 documented wound care completed to left lower medial leg trauma, posterior leg calf/laceration, and right lower lateral leg/skin tear unstageable. The RN routine visit on 5/27/2022 documented “catheter change today, 18 French, 10ml inserted, Macrobid ordered, WC (wound care) done this visit.” The plan of care was reviewed for 5/23/2022-7/23/2022 and revealed the plan of care did not identify the BLE wounds or foley catheter as a problem with planned interventions and goals. There was no documented evidence of a physician order for the foley catheter or wound care. Record 5: The patient’s date of election was 2/5/2022 with a primary diagnosis of Parkinsons’ disease. A registered nurse visit note on 8/6/2022 documented a wound assessment of “left hip, noted scant drainage with mild odor and reddened area. Wound covered with foam dressing. Facility staff updated on status of wound. Dr notified on status of wound. Bactrim DS ordered.” There was no documentation of a physician order for the wound care provided or Bactrim DS. A registered nurse visit note on 8/12/2022 documented “Pt does not c/o pain to left hip area. Site is red but drainage has decreased since last SNV…wound care performed. Forearm skin tears noted and wounds also cleaned and dressings applied to keep covered.” This visit note was not charted and signed by the RN until 8/30/2022. A physician order on 8/12/2022 states, "Perform wound care/dressing change: left lateral hip wound. Cleanse with wound cleanser, pat dry, apply foam dressing." The physician order was incomplete and did not include the frequency for the wound care. There was no documentation of a physician order for the wound care provided to the forearm skin tears. Further review of the record revealed the plan of care did not identify the hip wound as a problem with planned interventions until 8/29/2022, 23 days later after identified. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there was no documented evidence the plans of care identified specified the hospice care and services necessary to meet the specific needs of the patient and family, as identified in the comprehensive assessment

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed of patients with wounds revealed the hospice did not ensure the registered nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care. Record 1: The patient elected hospice care on 5/23/2022. The initial comprehensive assessment completed by the registered nurse (RN) on 5/23/2023 documented the patient’s bilateral lower extremity (BLE) wounds and Foley catheter in place. The RN visit note dated 5/25/2022 documented "wound care completed to left lower medial leg trauma, posterior leg calf/laceration, and right lower lateral leg/skin tear unstageable." In addition, the RN visit note dated 5/27/2022 documented, “catheter change today, 18 French, 10ml inserted, Macrobid ordered, WC (wound care) done this visit.” A review of the start of care plan of care dated 5/23/2022 through 7/23/2022 revealed the plan of care did not include the BLE wounds or Foley catheter as problems with planned interventions and goals. There was no evidence of physician orders for the Foley catheter or wound care. Record 5: The patient elected hospice care on 2/5/2022 with a primary diagnosis of Parkinson's disease. A clinical record review revealed the facility staff reported to the hospice social worker on 8/5/2022 that the patient had a new hip wound. The social worker reported this information to the registered nurse (RN) case leader (Staff #1). The RN (Staff #1) reported, "she was unable to visit this day and that a nurse would visit the next day." The RN visit note dated 8/6/2022 documented a wound assessment of “left hip, noted scant drainage with mild odor and reddened area. Wound covered with foam dressing. Facility staff updated on status of wound. Dr notified of status of wound. Bactrim DS ordered.” The RN visit was not documented in the record and signed until 8/13/2022, 7 days after the visit. The 8/11/2022 IDG note documented by the RN (Staff #1) did not include a discussion of the left hip wound reported by the social worker to the RN on 8/5/2022. Further review of the record revealed the plan of care did not identify the hip wound as a problem with planned interventions and goals from 8/5/2022 through 8/28/2022. The RN (Staff #1) visit note dated 8/12/2022 documented, “Pt does not c/o pain to left hip area. Site is red but drainage has decreased since last SNV…wound care performed. Forearm skin tears noted and wounds also cleaned and dressings applied to keep covered.” In addition the RN (Staff #1) visit note dated 8/15/2022 documented “dressing no longer in place, wc to left hip, no drainage.” Both visit notes were not documented in the record and signed by the nurse until 8/30/2022, which was 18 days and 15 days respectively after the visits. A verbal physician order entered by the registered nurse (Staff #1) on 8/12/2022 stated, "Perform wound care/dressing change: left lateral hip wound. Cleanse with wound cleanser, pat dry, apply foam dressing." There was no documentation of a physician order for the wound care provided to the forearm skin tears. Further review of the record revealed the plan of care did not identify the hip wound as a problem with planned interventions until 8/29/2022, 23 days after the social worker identified the wound. Wound care visits were documented on 8/15/2022 and 8/29/2022. There was no documented evidence that described if the facility provided the hip wound care during the period from 8/16/2022 through 8/28/2022. The RN documented in the visit note dated 8/31/2022, “Pt did complain of mild pain to left hip wound.” The RN visit note dated 9/2/2022 documented, “FLACC 4, pain active problem yes, left hip wound.” The plan of care did not identity the hip pain as a problem until discharge on 9/8/2022. During the week of 9/4/2022 through 9/10/2022, the physician ordered wound care "3 x week." There was no evidence of a nursing visit from 9/4/2022 through 9/10/2022 . An LPN missed visit note dated 9/5/2022 documented “unable to make visit due to holiday, action taken rescheduled, RN notified.” These deficient practices resulted in the patient experiencing pain in the left hip and a deterioration in his left hip wound requiring a second round of antibiotics and increased wound care frequency. The patient transferred to another hospice on 9/8/2022. The Hospice Medical Director (HMD) was interviewed on 2/14/2023 and stated, “I’m aware that wounds were missed and a nurse left.” Additionally, during interview on 2/14/2023, the Hospice Medical Director stated, “it can vary nurse to nurse with their experience in wounds” when asked about wound reporting by the nurses to the HMD. Additionally, during interview on 2/14/2023, the VP of Clinical Excellence confirmed, an investigation by the leadership team revealed there was a gap in care provided by the RN (Staff #1) from initial discovery of wound and follow up wound care. Record 1: The patient’s date of election was 5/23/2022 with a primary diagnosis of chronic diastolic (congestive) heart failure. The RN SOC (start of care) visit on 5/23/2022 identified BLE wounds, foley catheter in place. The RN Routine Visit on 5/25/2022 documented wound care completed to left lower medial leg trauma, posterior leg calf/laceration, and right lower lateral leg/skin tear unstageable. The RN Routine Visit on 5/27/2022 documented “catheter change today, 18 French, 10ml inserted, Macrobid ordered, WC (wound care) done this visit.” The plan of care was reviewed for 5/23/2022-7/23/2022 and revealed the plan of care did not identify the BLE wounds or foley catheter as a problem with planned interventions and goals. There was no documented evidence of a physician order for the foley catheter or wound care. Record 5: The patient’s date of election was 2/5/2022 with a primary diagnosis of Parkinsons’ disease. Review of the record revealed facility staff reported to the hospice social worker on 8/5/2022 that patient had a new hip wound. The social worker reported this information to the registered nurse case leader (Staff #1). The RN (Staff #1) reported she was unable to visit this day and that a nurse would visit next day. A registered nurse visit note on 8/6/2022 documented a wound assessment of “left hip, noted scant drainage with mild odor and reddened area. Wound covered with foam dressing. Facility staff updated on status of wound. Dr notified on status of wound. Bactrim DS ordered.” There was no documentation of a physician order for the wound care provided or Bactrim DS. A verbal order for the Bactrim DS. This visit note was not charted and signed by the RN until 8/13/2022, 7 days later. A Bactrim DS verbal order was entered by a registered nurse (Staff #1) 6 days later with a start date of 8/12/2022. The 8/11/2022 IDG note by the registered nurse did not include discussion or update regarding the left hip wound that was reported to the RN on 8/5/2022, wound care started 8/6/2022. Further review of the record revealed the plan of care did not identify the hip wound as a problem with planned interventions and goals between 8/5/2022-8/28/2022. A registered nurse (Staff #1) visit note on 8/12/2022 documented “Pt does not c/o pain to left hip area. Site is red but drainage has decreased since last SNV…wound care performed. Forearm skin tears noted and wounds also cleaned and dressings applied to keep covered.” This visit note was not charted and signed by the RN until 8/30/2022, 18 days later. A verbal physcian order entered by the registered nurse (Staff #1) on 8/12/2022 states, "Perform wound care/dressing change: left lateral hip wound. Cleanse with wound cleanser, pat dry, apply foam dressing." The physician order was incomplete and did not include the frequency for the wound care. There was no documentation of a physician order for the wound care provided to the forearm skin tears. Further review of the record revealed the plan of care did not identify the hip wound as a problem with planned interventions until 8/29/2022, 23 days later after identified. A registered nurse (Staff #1) visit note on 8/15/2022 documented “dressing no longer in place, wc to left hip, no drainage.” This visit note was not charted and signed by the nurse until 8/30/2022, 15 days later. Wound care visits were documented on 8/15/2022 and 8/29/2022. There was no documented evidence wound care was provided to the hip wound from 8/16/2022-8/28/2022, until the 14th day on 8/29/2022. During the week 8/21/2022-8/27/2022, there was no documented evidence of a nursing visit. The plan of care ordered skilled nursing 1 x week. A physician order on 8/12/2022 states, "Perform wound care/dressing change: left lateral hip wound. A registered nurse (Staff #1) missed visit note for 8/26/2022 revealed “no visit made, reason: other, action: physician made aware, no further action needed.” The missed visit documentation was not charted and signed by the registered nurse until 8/30/2022, 4 days later. A nurse visit on 8/29/2022 documented wound care completed. A physician order on 8/29/2022 revealed new wound care orders, “Perform wound care/dressing change. Left lateral hip wound. Clean wound with wound cleanser, pat dry with gauze, apply medihoney to wound bed and apply new dressing. Perform wound care 3x/wk. The patient started experiencing pain as noted in 8/31/2022 RN visit “Pt did complain of mild pain to left hip wound” and 9/2/2022 nurse visit, “FLACC 4, pain active problem yes, left hip wound.” The patient was started on a second antibiotic “Doxycycline Hyclate 100mg. Take 1 cap 2 x day for 7 days for infection, left hip wound” on 8/31/2022. The plan of care did not The plan of care did not identity the hip pain (or pain) as a problem with planned interventions or goals from the date identified 8/31/2022 until discharge on 9/8/2022. The plan of care did not address the use of Bactrim DS or Doxycycline Hyclate for infection of the left hip wound. During the week 9/4/2022-9/10/2022, wound care was ordered 3 x week. There was no documented evidence of a nursing visit. An LPN missed visit note on 9/5/2022 revealed “unable to make visit due to holiday, action taken rescheduled, RN notified.” These deficient practices resulted in the patient experiencing pain to left hip and a deterioration in his left hip wound requiring a second round of antibiotics and increased wound care frequency. The patient transferred to another hospice on 9/8/2022. The Hospice Medical Director (HMD) was interviewed on 2/14/2023 and stated, “I’m aware that wounds were missed and a nurse left.” Additionally, during interview on 2/14/2023, the Hospice Medical Director stated, “it can vary nurse to nurse with their experience in wounds” when asked about wound reporting by the nurses to the HMD . The VP of Clinical Excellence was interviewed on 2/14/2023 and stated, an investigation in the patient’s chart, after receiving a complaint, revealed concerns. Additionally, during interview on 2/14/2023, the VP of Clinical Excellence confirmed, an investigation by the leadership team revealed there was a gap in care provided by the RN (Staff #1) from initial discovery of wound and follow up wound care.

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. 2 of 5 (40%) records reviewed revealed that the hospice did not ensure that the care and services provided to patients followed the plan of care (POC). Record 5: The patient elected hospice care on 2/5/2022. During the week of 9/4/2022 through 9/10/2022, a physician order ordered wound care "3 x a week." There was no evidence of a nursing visit from 9/4/2022 through 9/10/2022. An LPN missed visit note dated 9/5/2022 documented “unable to make visit due to holiday, action taken rescheduled, RN notified.” There was no evidence of communication with the physician changing the frequency of visits. Record 2: The patient elected hospice care on 5/20/2022. The physician order dated 6/6/2022 ordered chaplain services "1 x m (month) for 3 months." There was no evidence of a chaplain visit for June or July. The patient died on 7/20/2022. There were no documented reasons for the missed visits. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed there was no evidence of chaplain visits for June and July 2022 or documented reasons for the missed visits. Record 2: The patient’s date of election was 5/20/2022 with a primary diagnosis of malignant neoplasm of unspecified ovary. A physician order on 6/6/2022 states a visit frequency of 1 x m (month) for 3 months. There was no documented evidence of a chaplain visit in June or in July (died 7/20) or documented reasons for the missed visit. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there was no documented evidence of a chaplain visit in June or July 2022 or documented reason for the missed visit. Record 5: The patient’s date of election was 2/5/2022 with a primary diagnosis of Parkinsons’ disease. The plan of care ordered skilled nursing 1 x week x 8 weeks beginning week of 8/10/2022. A physician order on 8/12/2022 states, "Perform wound care/dressing change: left lateral hip wound.” During the week 8/21/2022-8/27/2022, there was no documented evidence of a nursing visit. A missed visit note for 8/26/2022 by the registered nurse (Staff #1) revealed “no visit made, reason: other, action: physician made aware, no further action needed.” The missed visit documentation was not charted and signed by the registered nurse until 8/30/2022, 4 days later. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there was no documented evidence a nursing visit was made or that wound care was provided as ordered. Additionally, during interview on 2/14/2023, the VP of Clinical Excellence stated, “she admitted she didn’t go, said she was going through personal stuff. A visit should have been made that week to provide wound care but wasn’t.”

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. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed revealed the hospice did not ensure that each patient’s written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated assessments. Record 1: The patient elected hospice care on 5/23/2022. The initial comprehensive assessment completed by the registered nurse (RN) on 0/23/2022 documented the patient's bilateral lower extremity (BLE) wounds and Foley catheter in place. The RN visit note dated 5/25/2022 documented "wound care completed to left lower medial leg trauma, wound cleansing/dressing type: per care plan, cleansed with normal saline, vash, packing: plain packing strip, covered with dressing type: fibrocal, secured with kerlix then Coban; posterior leg calf/laceration, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing other: antifungal powder. Covered with Optifoam dressing, secured with kerlix; right lower lateral leg/skin tear unstageable, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing: Other: xeroform. Covered with dress type: non-adherent, secured with occlusive dressing." In addition, the RN visit note dated 5/27/2022 documented “catheter change today, 18 French, 10ml inserted, Macrobid ordered, WC (wound care) done this visit.” The plan of care effective from 5/23/2022 through 7/23/2022 did not include problems, interventions, or goals related to the BLE wounds or Foley catheter. There was no documented evidence of physician orders for the Foley catheter or wound care. Record 5: The patient elected hospice care on 2/5/2022. The RN visit note dated 8/6/2022 documented the wound assessment, “left hip, noted scant drainage with mild odor and reddened area. Wound covered with foam dressing. Facility staff updated on status of wound. Dr notified of status of wound. Bactrim DS ordered.” There was no evidence of a physician order for the wound care provided. The registered nurse visit note dated 8/12/2022 documented, “Pt does not c/o pain to left hip area. Site is red but drainage has decreased since last SNV…wound care performed. Forearm skin tears noted, and wounds also cleaned, and dressings applied to keep covered.” This visit note was documented and signed by the RN on 8/30/2022, 18 days after the visit was completed. A physician order dated 8/12/2022 stated, "Perform wound care/dressing change: left lateral hip wound. Cleanse with wound cleanser, pat dry, apply foam dressing." The physician order did not include the frequency of the wound care. There was no evidence of a physician's order for the wound care provided to the forearm skin tears. The plan of care did not include the hip wound as a problem with planned interventions until 8/29/2022, 23 days later after identified. The RN visit note dated 8/31/2022 documented “Pt did complain of mild pain to left hip wound.” The RN visit note dated 9/2/2022 documented, “FLACC 4, pain active problem yes, left hip wound.” The patient was started on “Doxycycline Hyclate 100mg. Take 1 cap 2 x day for 7 days for infection, left hip wound” on 8/31/2022. The plan of care did not identify the hip pain (or pain) as a problem with planned interventions or goals from the date identified 8/31/2022 until discharge on 9/8/2022. The plan of care did not address the use of Bactrim DS or Doxycycline Hyclate for infection of the left hip wound. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there was no documented evidence the plan of care was updated with planned interventions and patient goals based on problems identified in the assessments for the records identified. Record 1: The patient’s date of election was 5/23/2022 with a primary diagnosis of chronic diastolic (congestive) heart failure. The RN SOC (start of care) visit on 5/23/2022 identified BLE wounds, foley catheter in place. The RN Routine Visit on 5/25/2022 documented wound care completed to left lower medial leg trauma, wound cleansing/dressing type: per care plan, cleaned with normal saline, vash, packing: plain packing strip, covered with dressing type: fibrocal, secured with kerlix then coban; posterior leg calf/laceration, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing other: antifungal powder. Covered with optifoam dressing, secured with kerlix; right lower lateral leg/skin tear unstageable, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing: Other: xeroform. Covered with dress type: non-adherent, secured with occlusive dressing. The RN Routine Visit on 5/27/2022 documented “catheter change today, 18 French, 10ml inserted, Macrobid ordered, WC (wound care) done this visit.” The plan of care effective from 5/23/2022-7/23/2022 did not include any problems, interventions or goals related to the BLE wounds or foley catheter. There was no documented evidence of a physician order for the foley catheter or wound care. Record 5: The patient’s date of election was 2/5/2022 with a primary diagnosis of Parkinsons’ disease. A Registered nurse visit note on 8/6/2022 documented a wound assessment of “left hip, noted scant drainage with mild odor and reddened area. Wound covered with foam dressing. Facility staff updated on status of wound. Dr notified on status of wound. Bactrim DS ordered.” There was no documentation of a physician order for the wound care provided or Bactrim DS. A registered nurse visit note on 8/12/2022 documented “Pt does not c/o pain to left hip area. Site is red but drainage has decreased since last SNV…wound care performed. Forearm skin tears noted and wounds also cleaned and dressings applied to keep covered.” This visit note was not charted and signed by the RN until 8/30/2022. A physician order on 8/12/2022 states, "Perform wound care/dressing change: left lateral hip wound. Cleanse with wound cleanser, pat dry, apply foam dressing." The physician order was incomplete and did not include the frequency for the wound care. The patient started experiencing pain as noted in 8/31/2022 RN visit “Pt did complain of mild pain to left hip wound” and 9/2/2022 nurse visit, “FLACC 4, pain active problem yes, left hip wound.” The patient was started on a second antibiotic “Doxycycline Hyclate 100mg. Take 1 cap 2 x day for 7 days for infection, left hip wound” on 8/31/2022. There was no documentation of a physician order for the wound care provided to the forearm skin tears. Further review of the record revealed the plan of care did not identify the hip wound as a problem with planned interventions until 8/29/2022, 23 days later after identified. The plan of care did not identity the hip pain (or pain) as a problem with planned interventions or goals from the date identified 8/31/2022 until discharge on 9/8/2022. The plan of care did not address the use of Bactrim DS or Doxycycline Hyclate for infection of the left hip wound. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there was no documented evidence the plan of care was updated with planned interventions and patient goals based on problems identified in the assessments for the records identified.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed revealed the hospice did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the plan of care as frequently as the patient’s condition required but no less frequently than every 15 calendar days. Record 2: The patient elected hospice care on 5/20/2022 with a primary diagnosis of malignant neoplasm of unspecified ovary. A physician order dated 6/6/2022 ordered a chaplain visit frequency of "1 x month x 3 months." The Interdisciplinary Group (IDG) meetings dated 6/16/2022, 7/1/2022, and 7/14/2022 did not include IDG notes completed by the Chaplain. The sign-in sheets dated 7/1/2022 and 7/14/2022 did not include a Chaplain virtually or in person. There was no evidence the Chaplain reviewed and updated the individualized plan of care dated 6/16/2022 through 7/20/2022. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed the Chaplain did not review, revise, and document the individualized plans of care between 6/16/2022 and 7/20/2022. Additionally, during an interview on 2/14/2023, the VP of Clinical Excellence confirmed there was no evidence the Chaplain signed in or attended the IDG meetings dated 7/1/2022 and 7/14/2022. Record 5: The patient elected hospice care on 2/5/2022 with a primary diagnosis of Parkinson's disease. The physician ordered the chaplain visit frequency "1 x month x 3 months" for the plan of care dated 5/6/2022 through 7/31/2022. The Interdisciplinary Group (IDG) meetings dated 7/1/2022 and 7/14/2022 did not include IDG notes completed by the Chaplain. The sign-in sheets dated 7/1/2022 and 7/14/2022 did not include a Chaplain virtually or in person. There was no evidence the Chaplain reviewed, revised, and documented the individualized plan between 7/1/2022 and 7/27/2022. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed the Chaplain did not review, revise, and document the individualized plans of care between 6/16/2022 and 7/20/2022. Additionally, during an interview on 2/14/2023, the VP of Clinical Excellence confirmed there was no evidence the Chaplain signed in or attended the IDG meetings dated 7/1/2022 and 7/14/2022. Record 1: The patient’s date of election was 5/23/2022 with a primary diagnosis of chronic diastolic (congestive) heart failure. The RN visit on 5/25/2022 revealed, wound care completed to left lower medial leg trauma, wound cleansing/dressing type: per care plan, cleaned with normal saline, vash, packing: plain packing strip, covered with dressing type: fibrocal, secured with kerlix then coban; posterior leg calf/laceration, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing other: antifungal powder. Covered with optifoam dressing, secured with kerlix; right lower lateral leg/skin tear unstageable, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing: Other: xeroform. Covered with dress type: non-adherent, secured with occlusive dressing. The Interdisciplinary Group (IDG) meeting on 6/2/2022 documented “BLE wounds, bed bound as her recent BLE wounds have contributed to her immobility, SN-3x week for wound care.” There was no documented evidence the RN provided a specific update to the IDG on the patient’s BLE wounds, wound care interventions, response to treatment, foley catheter care or response to the new order for Macrobid. Further review of the record revealed the plan of care between 5/23/2022-7/23/2022 did not identify the BLE wounds or foley catheter as a problem with planned interventions and goals. There was no documented evidence of a physician order for the wound care or foley catheter. The Regional Director of Clinical Support and Education was interviewed on 2/14/2023 and agreed, there was no documented evidence the RN provided a specific update to the IDG on the patient’s BLE wounds, wound care interventions, response to treatment, foley catheter care or response to the new order for Macrobid. Record 2: The patient’s date of election was 5/20/2022 with a primary diagnosis of malignant neoplasm of unspecified ovary. The Interdisciplinary Group (IDG) meetings on 6/16/2022, 7/1/2022 and 7/14/2022 did not include an IDG note by the Chaplain. The sign in sheet for 7/1/2022 and 7/14/2022 did not include a Chaplain in attendance, virtually or in person. A physician order on 6/6/2022 ordered a chaplain visit frequency of 1 x month x 3 months. There was no documented evidence the Chaplain reviewed, revised and documented the individualized plan between 6/16/2022-7/20/2022. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there was no documented evidence the Chaplain reviewed, revised and documented the individualized plan between 6/16/2022-7/20/2022. Additionally, during interview on 2/14/2023, the VP of Clinical Excellence confirmed, there was no documented evidence the Chaplain signed in or attended the IDG meeting on 7/1/2022 or 7/14/2022. Record 5: The patient’s date of election was 2/5/2022 with a primary diagnosis of Parkinsons’ disease. The Interdisciplinary Group (IDG) meetings on 7/1/2022 and 7/14/2022 did not include an IDG note by the Chaplain. The sign in sheet for 7/1/2022 and 7/14/2022 did not include a Chaplain in attendance, virtually or in person. A physician order for chaplain visit frequency ordered 1 x month x 3 months for 5/6/2022-7/31/2022. There was no documented evidence the Chaplain reviewed, revised and documented the individualized plan between 7/1/2022-7/27/2022. Additionally, the 8/11/2022 IDG note by the registered nurse did not include discussion or update regarding the left hip wound reported to the RN on 8/5/2022, wound care started 8/6/2022. Further review of the record revealed the plan of care did not identify the hip wound as a problem with planned interventions and goals between 8/5/2022-8/28/2022. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there was no documented evidence the Chaplain reviewed, revised and documented the individualized plan between 7/1/2022-7/28/2022. Additionally, during interview on 2/14/2023, the VP of Clinical Excellence confirmed, there was no documented evidence the Chaplain signed in or attended the IDG meeting on 7/1/2022 or 7/14/2022. The VP of Clinical Excellence also confirmed during interview on 2/14/2023, there was no documented evidence the left hip wound was reviewed with the IDG during the 8/11/2022 IDG meeting.

It is required that a revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed revealed the agency did not ensure that the patients plan of care was updated to include information from the patient’s updated comprehensive assessment. Record 1: The patient elected hospice care on 5/23/2022 with a primary diagnosis of chronic diastolic (congestive) heart failure. The initial comprehensive assessment completed by the registered nurse (RN) on 5/23/2022 documented the patient's bilateral lower extremity (BLE) wounds and Foley catheter in place. The RN visit note dated 5/25/2022 documented, "wound care completed to left lower medial leg trauma, wound cleansing/dressing type: per care plan, cleansed with normal saline, vash, packing: plain packing strip, covered with dressing type: fibrocal, secured with kerlix then Coban; posterior leg calf/laceration, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing other: antifungal powder. Covered with Optifoam dressing, secured with kerlix; right lower lateral leg/skin tear unstageable, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing: Other: xeroform. Covered with dress type: non-adherent, secured with occlusive dressing." In addition, the RN visit note dated 5/27/2022 documented “catheter change today, 18 French, 10ml inserted, Macrobid ordered, WC (wound care) done this visit.” The Interdisciplinary Group (IDG) meeting note dated 6/2/2022 documented “BLE wounds, bed bound as her recent BLE wounds have contributed to her immobility, SN-3x week for wound care.” There was no evidence that the RN provided an update to the IDG on the patient’s BLE wounds, wound care interventions, response to treatment, Foley catheter care, or response to the new order for Macrobid. The Regional Director of Clinical Support and Education were interviewed on 2/14/2023 and agreed there was no evidence the RN provided the IDG an update on the patient’s BLE wounds, wound care interventions, response to treatment, Foley catheter care or response to the new order for Macrobid. Further review of the record revealed the plan of care dated 5/23/2022 through 7/23/2022 did not include and was not updated to reflect the BLE wounds and Foley catheter as problems with planned interventions and goals. Record 5: The patient elected hospice care on 2/5/2022 with a primary diagnosis of Parkinson's disease. A record review revealed that facility staff reported to the hospice social worker on 8/5/2022 that the patient had a new hip wound. The social worker reported this information to the registered nurse case leader (Staff #1) on 8/5/2022. The RN visit note dated 8/6/2022 documented the wound assessment, “left hip, noted scant drainage with mild odor and reddened area. Wound covered with foam dressing. Facility staff updated on the status of the wound. Dr notified on the status of the wound. Bactrim DS ordered.” The 8/11/2022 IDG note completed by the registered nurse did not include a discussion or an update regarding the patient's left hip wound and the addition of Bactrim DS. The VP of Clinical Excellence was interviewed on 2/14/2023 and confirmed there was no evidence that the left hip wound was reviewed with the IDG during the 8/11/2022 IDG meeting.

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: physician orders. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed revealed the hospice did not ensure the clinical record included physician’s orders for care provided. Record 1: The patient elected hospice care on 5/23/2022 with a primary diagnosis of chronic diastolic (congestive) heart failure. The initial comprehensive assessment completed by the registered nurse (RN) on 5/23/2022 documented the patient's bilateral lower extremity (BLE) wounds and Foley catheter in place. The RN visit note dated 5/25/2022 documented "wound care completed to left lower medial leg trauma, wound cleansing/dressing type: per care plan, cleansed with normal saline, vash, packing: plain packing strip, covered with dressing type: fibrocal, secured with kerlix then Coban; posterior leg calf/laceration, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing other: antifungal powder. Covered with Optifoam dressing, secured with kerlix; right lower lateral leg/skin tear unstageable, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing: Other: xeroform. Covered with dress type: non-adherent, secured with occlusive dressing." In addition, the RN visit note dated 5/27/2022 documented “catheter change today, 18 French, 10ml inserted, Macrobid ordered, WC (wound care) done this visit.” There was no evidence of physician orders for the Foley catheter or wound care. The Vice President (VP)of Clinical Excellence was interviewed on 2/14/2023 and agreed there were no physician’s orders between 5/23/2022-7/23/2022 for the wound care and Foley catheter care provided. Record 5: The patient elected hospice care on 2/5/2022 with a primary diagnosis of Parkinson's’ disease. The RN visit note dated 8/6/2022 documented “left hip, noted scant drainage with mild odor and reddened area. Wound covered with foam dressing. Facility staff updated on status of wound. Dr notified of status of wound. Bactrim DS ordered.” There was no evidence of a physician's order for the wound care provided. The registered nurse visit note dated 8/12/2022 documented, “Pt does not c/o pain to left hip area. Site is red but drainage has decreased since last SNV…wound care performed. Forearm skin tears noted and wounds also cleaned and dressings applied to keep covered.” A physician order dated 8/12/2022 stated, "Perform wound care/dressing change: left lateral hip wound. Cleanse with wound cleanser, pat dry, apply foam dressing." The physician's order did not include the frequency of the wound care. There was no evidence of a physician's order for the wound care provided to the forearm skin tears. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed there were no wound care orders for the left hip wound care provided on 8/6/2022 or the forearm skin tear wound care provided on 8/12/2022. Additionally, during an interview on 2/14/2023, the VP of Clinical Excellence stated the left hip wound care order on 8/12/2022 was incomplete and did not include a frequency for wound care. Record 1: The patient’s date of election was 5/23/2022 with a primary diagnosis of chronic diastolic (congestive) heart failure. The RN SOC (start of care) visit on 5/23/2022 identified BLE wounds, foley catheter in place. The RN Routine Visit on 5/25/2022 documented wound care completed to left lower medial leg trauma, wound cleansing/dressing type: per care plan, cleaned with normal saline, vash, packing: plain packing strip, covered with dressing type: fibrocal, secured with kerlix then coban; posterior leg calf/laceration, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing other: antifungal powder. Covered with optifoam dressing, secured with kerlix; right lower lateral leg/skin tear unstageable, wound cleansing/dressing type: per care plan, cleansed with normal saline, application/packing: Other: xeroform. Covered with dress type: non-adherent, secured with occlusive dressing. The RN Routine Visit on 5/27/2022 documented “catheter change today, 18 French, 10ml inserted, Macrobid ordered, WC (wound care) done this visit.” The plan of care was reviewed for 5/23/2022-7/23/2022 and revealed the plan of care did not identify the BLE wounds or foley catheter as a problem with planned interventions and goals. There was no documented evidence of a physician order for the foley catheter or wound care. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there were no physician’s orders between 5/23/2022-7/23/2022 for the wound care and foley catheter care provided. Record 5: The patient’s date of election was 2/5/2022 with a primary diagnosis of Parkinsons’ disease. A registered nurse visit note on 8/6/2022 documented a wound assessment of “left hip, noted scant drainage with mild odor and reddened area. Wound covered with foam dressing. Facility staff updated on status of wound. Dr notified on status of wound. Bactrim DS ordered.” There was no documentation of a physician order for the wound care provided. A registered nurse visit note on 8/12/2022 documented “Pt does not c/o pain to left hip area. Site is red but drainage has decreased since last SNV, wound care performed. Forearm skin tears noted and wounds also cleaned and dressings applied to keep covered.” A physician order on 8/12/2022 states, "Perform wound care/dressing change: left lateral hip wound. Cleanse with wound cleanser, pat dry, apply foam dressing." The physician order was incomplete and did not include the frequency for the wound care. There was no documentation of a physician order for the wound care provided to the forearm skin tears. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, there were no wound care orders for the left hip wound care provided on 8/6/2022 or the forearm skin tear wound care provided on 8/12/2022. Additionally, during interview on 2/14/2023, the VP of Clinical Excellence stated, the left hip wound care order on 8/12/2022 was incomplete and did not include a frequency for wound care.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 2 of 5 (40%) records reviewed revealed the hospice did not ensure that clinical record documentation was completed in accordance with the hospice policy. The agency policy #6-043, "Assembly of the Clinical Record" (revised April 2019), stated in part, “Documentation in the record will be entered no later than 24 hours after patient contact/visit has concluded.” Record 1: The patient elected hospice care on 5/23/2022. A registered nurse (RN Staff #1) visit completed on 5/23/2022 was documented in the record and signed by the RN on 5/29/2022, 6 days after the visit. Record 5: The patient elected hospice care on 2/5/2022. The RN visit completed on 8/6/2022 was documented in the record and signed by the RN on 8/13/2022, 7 days after the visit. The RN (Staff #1) visit completed on 8/12/2022 was documented in the record and signed by the RN on 8/30/2022, 18 days after the visit. The RN (Staff #1) visit completed on 8/15/2022 was documented in the record and signed by the RN on 8/30/2022, 15 days after the visit. The RN (Staff #1) missed a visit on 8/26/2022. The missed visit was documented in the record and signed by the RN (Staff #1) on 8/30/2022, 4 days after the visit was missed. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed the clinical documentation was not completed within 24 hours as policy requires. Agency Policy #6-043 [revised April 2019] titled Assembly of the Clinical Record, stated in part, “Documentation in the record will be entered no later than 24 hours after patient contact/visit has concluded.” Record 1: The patient’s date of election was 5/23/2022 with a primary diagnosis of chronic diastolic (congestive) heart failure. A registered nurse (Staff #1) visit was done on 5/23/2022 and charted and signed by the registered nurse on 5/29/2022, 6 days later. Record 5: The patient’s date of election was 2/5/2022 with a primary diagnosis of Parkinsons’ disease. A registered nurse visit was done on 8/6/2022 and charted and signed by the Registered nurse on 8/13/2022, 7 days later. A registered nurse (Staff #1) visit was done on 8/12/2022 and charted and signed by the registered nurse on 8/30/2022, 18 days later. A registered nurse (Staff #1) visit was done on 8/15/2022 and charted and signed by the registered nurse on 8/30/2022, 15 days later. A registered nurse (Staff #1) missed visit on 8/26/2022 was charted and signed by the registered nurse on 8/30/2022, 4 days later. The VP of Clinical Excellence was interviewed on 2/14/2023 and agreed, the clinical documentation was not completed within 24 hours as required by policy. Additionally, during interview on 2/14/2023, the VP of Clinical Excellence stated, the registered nurse (Staff #1) signed charting expectations upon hire on 2/14/2022 and coaching was initiated on 5/24/2022 regarding open clinical documentation from 5/10/2022.