All Care Hospice Inc.

“It is required that the Continuous Quality Improvement (CQI) program is organization-wide and covers all services and programs offered, including those provided under contract or arrangement. The organization maintains documentary evidence of its quality assessment and performance improvement program and is able to demonstrate its operation. The program is capable of showing measurable improvement in indicators related to outcomes, patient safety, and quality of care. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of the agency’s Quality Improvement program, administrative documents, and interviews with the Director of Nursing and Alternate Director of Nursing which revealed the following issues with the CQI program: Failure to ensure the governing body was responsible for ensuring and approving the agency’s QAPI [Quality Assurance Performance Improvement] program included defined data detail and frequency of collection [HQPI.1.D/L565]; Failure to ensure the governing body appointed an individual responsible for operating the agency’s QAPI program [HQIP.2.I/L576]; Failure to ensure the QAPI program demonstrated measurable outcomes related to palliative outcomes [HQIP.3.I/L561]; and Failure to ensure the QAPI program collected data to monitor the effectiveness and safety of services and quality of care [HQPI.5.I/L564]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.58: Quality Assessment and Performance Improvement. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care from the agency. Quality program has consisted of 4 PIPs (performance improvement programs) that include review by the DON and the Alt DON. These have not been presented at hospice wide meetings. PIPs involve volunteer onboarding, inservice/competency (staff completion rates), switching from Medline to McKesson due to supply delivery issues and initial aide frequency physician orders. No governing body, physician, other licensed professional involvement, no measurable data tracking. Numerical data is not well-defined and measurable.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by clinical record review, observation, interviews, and review of findings with the Director of Nursing, which revealed the following issues regarding Hospice Aide services: Failure to ensure the Registered Nurse provided patient specific care instructions for the hospice aide [HCDT.15.I/L625]; Failure to ensure the Hospice Aide provided services included in the plan of care [HCDT.16.I/L626]; and Failure to ensure supervisory visits completed by the Registered Nurse assessed the quality of care and services provided by the hospice aide and ensured that the aide services ordered by the hospice interdisciplinary group meet the patient’s needs [HSRM.25.I/L629]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice 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. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group completed the initial comprehensive assessment within five calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 07/23/2024 for the diagnosis of heart failure. The Spiritual Counselor documented in a note dated 07/24/2024 the “stepson said to wait a few days” for the initial spiritual assessment visit. There was no documented evidence in the clinical record that the initial spiritual assessment was completed as part of the initial comprehensive assessment, as of the date of record review on 08/06/2024. A total of thirteen days after the election of benefits and eight days outstanding. Clinical Record 5: The patient elected the hospice benefit on 11/01/2023 for the diagnosis of Alzheimer’s disease. The Social Worker documented the initial psychosocial assessment as part of the initial comprehensive assessment on 11/18/2023, a total of seventeen days after the election of benefits and twelve days outstanding. Clinical Record 6: The patient elected the hospice benefit on 06/01/2024 for the diagnosis of malignant neoplasm of the prostate. There was no documented evidence in the clinical record that the Spiritual Counselor completed the initial spiritual assessment as part of the initial comprehensive assessment. Clinical Record 7: The patient elected the hospice benefit on 06/04/2024 for the diagnosis of chronic heart failure. The Spiritual Counselor documented the initial spiritual assessment as part of the initial comprehensive assessment on 06/25/2024, a total of twenty-one days after the election of benefits and sixteen days outstanding. Clinical Record 8: The patient elected the hospice benefit on 06/11/2024 for the diagnosis of cerebrovascular disease. The Spiritual Counselor documented the initial spiritual assessment as part of the initial comprehensive assessment on 06/28/2023, seventeen days after the election of benefits and twelve days outstanding. During an interview and joint record review on 08/06/2024, the Director of Nursing (DON) confirmed the initial assessments had been completed outside of the 5-day requirements. The DON stated in the case of the Spiritual Counselor this was “right before her retirement while she was having health issues.” The social worker’s initial comprehensive assessment was completed on 7/23/2024, seven (7) days after the election of benefits and two (2) days outstanding.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements; herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure an accurate medication review was completed to identify actual and potential drug interactions. Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 07/23/2024 for the diagnosis of heart failure. The patient resided at a board and care facility. During the home visit observation with the Hospice Aide (HA) (Personnel Record 6), a medication review was completed by comparing the hospice medication list to the board and care medication list. The board and care medication list contained one medication not listed on the hospice medication list, Xanax 0.5 mg twice a day as needed, and the hospice medication list contained two medications not listed on the facility list, Doxycycline and Lasix. Home Visit 2/Clinical Record 2: The patient elected the hospice benefit on 03/18/2024 for the diagnosis of malignant neoplasm of the ovary. The patient resided at a board and care facility. During the home visit observation with the Registered Nurse (RN) (Personnel Record 3), a medication review was completed by comparing the hospice medication list to the board and care medication list. The hospice medication list contained one medication not listed on the board and care medication list, Eliquis. During an interview and joint record review on 08/06/2024, the Director of Nursing confirmed the medication lists had not been reconciled with the board and care medication list.”

“It is required that the QAPI [Quality Assurance Performance Improvement] program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard is not met as evidenced by document review and interview. The agency did not ensure the QAPI program demonstrated measurable improvement related to palliative outcomes and hospice services. Review of the agency’s quality program and documents revealed the hospice did not have a defined quality program. The Director of Nursing and the Alternate Director of Nursing provided documentation that they had initiated 4 PIPs [performance improvement projects] as part of the QAPI program. The PIPs included volunteer onboarding, in-service/competency related to staff completion rates, switching supply companies related to supply delivery issues, and initial aide frequency per physician orders. Review of the quality documents and PIPs revealed that the agency did not collect data to demonstrate measurable improvement related to palliative outcomes of care and hospice services provided by the hospice agency. During an interview and joint review of quality documents with the Director of Nursing [DON] on 08/06/2024, the DON stated that she now had a better understanding of how to run a QAPI program and agreed the current program did not include evaluation of palliative outcomes of care.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data collected is used to monitor the effectiveness and safety of services and quality of care. This standard is not met as evidenced by document review and interview. The agency did not ensure the QAPI program collected data to monitor the effectiveness and safety of services and quality of care. Review of the agency’s quality program and documents revealed the hospice did not have a defined quality program. The Director of Nursing and the Alternate Director of Nursing provided documentation that they had initiated 4 PIPs [performance improvement projects] as part of the QAPI program. The PIPs included volunteer onboarding, in-service/competency related to staff completion rates, switching supply companies related to supply delivery issues, and initial aide frequency per physician orders. Review of the quality documents and PIPs revealed that the agency was not collecting data to monitor the effectiveness and safety of services and quality of care. During an interview and joint review of quality documents with the Director of Nursing [DON] on 08/06/2024, the DON stated that she now had a better understanding of how to run a QAPI program and agreed the current program did not include data collection to monitor the effectiveness and safety of services and quality of care.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program includes defined data detail and frequency of collection and approves such. This standard is not met as evidenced by document review and interview. The agency did not ensure the governing body was responsible for ensuring and approving the agency’s QAPI program included defined data detail and frequency of collection. Review of the agency’s quality program and documents revealed the hospice did not have a defined quality program. The Director of Nursing and the Alternate Director of Nursing provided documentation that they had initiated 4 PIPs [performance improvement projects] but there was no documented evidence that the governing body had reviewed or approved the performance improvement projects or a QAPI program for the agency. During an interview and program review on 08/06/2024, the Director of Nursing stated the PIPs had not been presented to the governing body for approval.”

“It is required that one or more individual(s) is appointed by the governing body as responsible for operating the QAPI program. This standard is not met as evidenced by document review and interview. The agency did not ensure the governing body appointed an individual responsible for operating the agency’s QAPI program. Review of the agency’s quality program and documents revealed the hospice did not have a defined quality program. The Director of Nursing [DON] and the Alternate Director of Nursing provided documentation that they had initiated 4 PIPs [performance improvement projects] as part of the QAPI program. During an interview and program review on 08/06/2024, the DON was asked if the governing body had appointed an individual to be responsible for the agency’s QAPI program. The DON was unable to provide evidence that the governing body had appointed someone to be responsible for the QAPI program.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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 clinical record review, observation, and interview. In 3 of 14 (21%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient specific care instructions for the hospice aide. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/23/2024 for the diagnosis of heart failure. During the home visit observation with the Hospice Aide (HA) (Personnel Record 1), the patient was observed to have a gastronomy tube (G-Tube) with nutritional supplements flowing continuously from a programmed machine. The patient was also observed to have continuous Oxygen via nasal cannula. The HA was observed to remove the Oxygen from the patient and asked the patient if he/she wanted “to stop the feedings for the bath today?” The Hospice Aide care plan did not include instructions for the aide for the patient’s Oxygen use, including if the Oxygen could be removed for a bath and cares, and did not include instructions for the aide related to the patient’s G-tube with continuous nutrition supplements. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 03/18/2024 for the diagnosis of malignant neoplasm of the ovary. The Hospice Aide care plan dated 03/18/2024 assigned the aide the task of “catheter care.” During an interview and joint record review on 08/06/2024, the Director of Nursing confirmed the patient did not have a catheter while on hospice services. Clinical Record 11: The patient elected the hospice benefit on 03/20/2023 for the diagnosis of Alzheimer’s disease. The Hospice Aide care plan dated 03/20/2023 assigned the aide the tasks to “Provide a complete bed bath PRN (as needed) and a shower every visit.” The clinical record included documentation that the patient was confused and was unable to choose the type of bath safely. The Hospice Aide care plan did not provide patient specific written bath instructions for the aide on the bath type to provide to the patient. During an interview and joint record review on 08/06/2024, the Director of Nursing stated, “aide care plans in hospice were very different than the hospital and I realized where these needed to be clarified after the review.””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, observation, and interview. In 4 of 14 (29%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide provided services included in the plan of care. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/23/2024 for the diagnosis of heart failure. The Hospice Aide care plan dated 07/23/2024 assigned the aide the task of “bathing via a shower.” During home visit observation with the Hospice Aide (HA) (Personnel Record 6), the HA was observed to provide the patient with a bed bath during the visit. The HA did not provide a shower as assigned on the aide care plan. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 03/18/2024 for the diagnosis of malignant neoplasm of the ovary. The Hospice Aide care plan dated 03/18/2024 assigned the aide the task of “bathing via shower and catheter care.” The Hospice Aide documented on the aide visit note dated 06/20/2024 “Client had just finished eating. I gave [the patient] a bed bath,” and on the aide visit note dated 07/11/2024 “I gave [the patient] a bed bath.” The aide marked catheter care “completed” every visit however further clinical record review and interview with the Director of Nursing revealed the patient did not have a catheter while on hospice services. Clinical Record 4: The patient elected the hospice benefit on 04/24/2024 for the diagnosis of Alzheimer’s disease. The Hospice Aide care plan dated 04/24/2024 assigned the aide the task of “bathing via a shower.” The Hospice Aide documented on the aide visit note dated 05/01/2024 “changed to bed bath from shower as patient being combative.” The Hospice Aide care plan was updated from a shower to a bed bath on 05/15/2024. The Hospice Aide documented on the aide visit note dated 06/25/2024 “I gave [the patient] a shower.” The HA provided a shower to the patient after the care plan was changed to assign a bed bath. Clinical Record 9: The patient elected the hospice benefit on 07/04/2024 for the diagnosis of senile degeneration of the brain. The Hospice Aide care plan dated 07/04/2024 assigned the aide the task of “bathing via a shower.” The Hospice Aide documented on the aide visit dated 07/15/2024 “Client not feeling good to get in the shower. I gave [patient] a bed bath.” During an interview and joint record review with the Director of Nursing on 08/06/2024, it was confirmed that the hospice aide(s) were not providing services as assigned in the plan of care. The Director of Nursing stated when “she first learned about the aide plans of care they were utilizing templates but then she began individualizing them.””

“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. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed with aide services provided, the agency did not ensure supervisory visits completed by the Registered Nurse assessed the quality of care and services provided by the hospice aide and ensured that the aide services ordered by the hospice interdisciplinary group meet the patient’s needs. Clinical Record 1: The patient elected the hospice benefit on 07/23/2024 for the diagnosis of heart failure. Clinical record review revealed that aide supervisory notes completed by the Registered Nurse (RN) did not include documentation that the RN assessed the quality of care and services provided by the hospice aide and ensured that the aide services ordered by the hospice interdisciplinary group meet the patient’s needs. Clinical Record 2: The patient elected the hospice benefit on 03/18/2024 for the diagnosis of malignant neoplasm of the ovary. Clinical record review revealed that aide supervisory notes completed by the Registered Nurse (RN) did not include documentation that the RN assessed the quality of care and services provided by the hospice aide and ensured that the aide services ordered by the hospice interdisciplinary group meet the patient’s needs. Clinical Record 4: The patient elected the hospice benefit on 04/24/2024 for the diagnosis of Alzheimer’s disease. Clinical record review revealed that aide supervisory notes completed by the Registered Nurse (RN) did not include documentation that the RN assessed the quality of care and services provided by the hospice aide and ensured that the aide services ordered by the hospice interdisciplinary group meet the patient’s needs. Clinical Record 5: The patient elected the hospice benefit on 11/01/2023 for the diagnosis of Alzheimer’s disease. Clinical record review revealed that aide supervisory notes completed by the Registered Nurse (RN) did not include documentation that the RN assessed the quality of care and services provided by the hospice aide and ensured that the aide services ordered by the hospice interdisciplinary group meet the patient’s needs. Clinical Record 9: The patient elected the hospice benefit on 07/04/2024 for the diagnosis of senile degeneration of the brain. Clinical record review revealed that aide supervisory notes completed by the Registered Nurse (RN) did not include documentation that the RN assessed the quality of care and services provided by the hospice aide and ensured that the aide services ordered by the hospice interdisciplinary group meet the patient’s needs. Clinical Record 11: The patient elected the hospice benefit on 03/20/2023 for the diagnosis of Alzheimer’s disease. Clinical record review revealed that aide supervisory notes completed by the Registered Nurse (RN) did not include documentation that the RN assessed the quality of care and services provided by the hospice aide and ensured that the aide services ordered by the hospice interdisciplinary group meet the patient’s needs. During an interview and joint record review on 08/06/2024, the Director of Nursing and Alternative Director of Nursing stated that during the supervisory visits they asked if the aide(s) showed up for visits and if the patient and family were happy with the care. They stated that they did not review the notes and the care plans or revise the care plans. In each of the clinical records below, the aides were providing care that was not following the care plan by either marking tasks as completed or performing a task not listed on the care plans. The registered nurses were performing supervisory visits but were not assessing the quality of the services or checking the care plans. In the instance of Clinical Record 11, the aide care plan listed the patient as having a Foley catheter and the aide was checking care completed when in fact the patient never had a catheter. In 2 patients, the aide was tasked with taking vital signs and did not list out these vital signs.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. Orientation includes the following, as appropriate to the employee’s specific job duties. This standard was not met as evidenced by document review, personnel record review, and interview. In 3 of 7 (43%) personnel records reviewed, the agency did not ensure the initial orientation addressed the employee’s job specific duties. Personnel Record 4: Social Worker/Volunteer Coordinator date of hire 07/24/2023. The personnel record contained no documented evidence that the employee was provided with a job description or information outlining job specific duties. Personnel Record 5: Spiritual Counselor/Bereavement Coordinator date of hire 06/18/2024. The personnel record contained no documented evidence that the employee was provided with a job description or information outlining job specific duties for the bereavement coordinator. Personnel Record 6: Hospice Aide date of hire 03/28/2024. The personnel record contained no documented evidence that the employee was provided with a job description or information outlining job specific duties. Personnel Record 7: Volunteer date of hire 02/01/2024. The personnel record contained no documented evidence that the employee was provided with a job description or information outlining job specific duties. During an interview and joint record review on 08/05/2024, the Director of Nursing confirmed the job descriptions were not in the personnel files.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, personnel record review, and interview. In 5 of 7 (71%) personnel records reviewed, the agency did not ensure hospice skills and competencies were assessed for individuals providing care and services as required by agency policy. Agency policy No. 1-002-2 Competencies, November 2022, required in part, “Must demonstrate competency during orientation and during probation period, according to orientation checklists. Must have continued review as part of their annual performance via the competency checklists.” Personnel Record 1: Medical Director date of hire 06/10/2024. Personnel record review revealed no documented evidence of competency assessment for this direct care employee. Personnel Record 3: Director of Nursing date of hire 10/24/2022. Personnel record review revealed the initial competency assessment was not checked off and signed by the evaluating nurse. The personnel record contained no documented evidence of a competency assessment for 2023. Personnel Record 4: Social Worker/Volunteer Coordinator date of hire 07/24/2023. Personnel record review revealed no documented evidence of competency assessment for this direct care employee. Personnel Record 5: Spiritual Counselor/Bereavement Coordinator date of hire 06/18/2024. Personnel record review revealed no documented evidence of competency assessment for this direct care employee. Personnel Record 7: Volunteer date of hire 02/01/2024. Personnel record review revealed no documented evidence of competency assessment for this direct care employee. During an interview and joint record review on 08/05/2024, the Director of Nursing confirmed the competencies were not present in the files or had not been completed per policy.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with patient live discharge, the agency did not ensure the discharge summary included a summary of the patient’s current plan of care. Clinical Record 11: The patient elected the hospice benefit on 03/20/2023 for the diagnosis of Alzheimer’s disease. The patient was discharged for extended prognosis and a review of the clinical record revealed the discharge summary did not include a summary of the patient’s current plan of care. During an interview and joint record review on 08/06/2024, the Director of Nursing confirmed the discharge summary did not include the patient’s current plan of care. The Director of Nursing stated, “I wrote the summary as I was trying to get them to home health and make sure they got the infection taken care of, but I will know what to include next time.””