A Tlc Hospice LLC

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed with patient live discharge, the agency did not ensure documentation that the patient participated in development of the plan of care and signed discharge forms per agency policy. Agency policy 0-125 Discharge from Hospice Program, required in part, “The organization will inform the family both verbally and in writing, including a timeline for discontinuing services.” Clinical Record 4: The patient was discharged for extended prognosis on 11/05/2024. There was no documented evidence in the clinical record that the patient was provided with the Notification of Medicare Non-Coverage Form. During an interview on 11/25/2024, the Hospice Clinical Director confirmed the Notification of Medicare Non-Coverage was not in the clinical record. She stated, “The nurse said she did it and put it in her car, but we do not have any evidence it was done.””

“It is required that a hospice aide provides 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 CONTINUING REQUIRED ACTION. This standard was not met as evidenced by document review and interview. Review of the agency’s plan of correction revealed the agency did not ensure implementation of the plan of correction for this standard cited during the site visit of 10/17/2024. The agency’s plan of correction included documentation that “On 10/26/24 all hospice aides of the agency were brought in for an in-service and meeting on the above deficiency. All signed in to an attendance sheet and all were instructed that the aide plan of care designed by the RN must be followed as listed. All aides were taught and reinforced that the plan of care for the patient cannot be changed by the aide. The education was provided by the Clinical Director on 10/26/24 with signing and dating an understanding of the aide plan of care and what the requirements are.” During an interview and review of the plan of correction on 11/25/2024, the Hospice Clinical Director stated, “We trained one hospice aide, but three more hospice aides currently seeing patients need to receive the education.” The Hospice Clinical Director confirmed that the agency had one full-time aide, and this aide had been in-serviced as described in the plan of correction, but there were 3 part-time aides that had not received the in-service information. The Clinical Director confirmed the part-time aides were providing care to the patients. The Agency’s Action Plan reviewed on 11/25/2024 revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 10/26/2024. Previous Evidence: “This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) home visits, with completed with a hospice aide, revealed the agency did not ensure that the hospice aide provided services included in the plan of care. Home Visit 1/Clinical Record 1: During the home visit, on 10/16/2024 with the hospice aide (Personnel Record 7), the aide was observed performing a sponge bath instead of a shower. The aide plan of care (dated 04/11/2023) included the following orders for the hospice aide “visit frequency of two times per week and the shower to be provided every visit.” During an interview with the Director of Nursing on 10/16/2024 it was determined the aide care plan had not been followed.””

“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. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by document review and interview. Review of the agency’s plan of correction revealed the agency did not ensure implementation of the plan of correction for this standard cited during the site visit of 10/17/2024. The agency’s plan of correction included documentation that “On 10/26/24 all hospice aides of the agency were brought in for an in-service and meeting on the above deficiency. All signed in to an attendance sheet and all were instructed that the aide plan of care designed by the RN must be followed as listed. All aides were taught and reinforced that the plan of care for the patient cannot be changed by the aide. The education was provided by the Clinical Director on 10/26/24 with signing and dating an understanding of the aide plan of care and what the requirements are.” During an interview and review of the plan of correction on 11/25/2024, the Hospice Clinical Director stated, “We trained one hospice aide, but three more hospice aides currently seeing patients need to receive the education.” The Hospice Clinical Director confirmed that the agency had one full-time aide, and this aide had been in-serviced as described in the plan of correction, but there were 3 part-time aides that had not received the in-service information. The Clinical Director confirmed the part-time aides were providing care to the patients. The Agency’s Action Plan reviewed on 11/25/2024 revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 10/26/2024. Previous evidence: “This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide reported changes to a registered nurse. Clinical Record 7: The hospice aide care plan dated 09/27/2024 contained the following tasks to be completed every visit at a frequency of 2 times per week: oral care, shave, and range of motion. On the hospice aide visits dated 10/07/2024, 10/10/2024, and 10/14/2024 those tasks were marked “No”. The record lacked documentation the aide had notified the registered nurse the task(s) had not been completed as ordered in the plan of care. Clinical Record 10: The hospice aide care plan dated 08/21/2024 contained the following tasks to be completed every visit at a frequency of 2 times per week: oral care, foley care, nail care, ambulate, and toilet. On the hospice aide visits dated 09/23/2024, 10/07/2024, 10/10/2024, and 10/14/2024, those tasks were marked “No.” The record lacked documentation the aide had notified the registered nurse the task(s) had not been completed as ordered in the plan of care. A joint clinical record review and interview was conducted with the Director of Nursing and Chief Clinical Officer on 10/16/2024 during which time they agreed the aide did not complete the tasks as assigned on the care plans and there was no documentation of a report to a registered nurse included in the clinical records.””

“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. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure entries in the patient record were completed as required by agency policy. Agency policy 3-007 Clinical Record Review, required in part, “The timeliness of entries into the clinical record by all disciplines should be completed within seven (7) days after each visit.” Clinical Record 4: The patient was discharged for extended prognosis on 11/05/2024. There was no documented evidence in the clinical record of the signed Notification of Medicare Non-Coverage Form. During an interview on 11/25/2024, the Hospice Clinical Director agreed that the Notification of Medicare Non-Coverage was not in the clinical record. She stated, “The nurse said she did it and put it in her car, but we do not have any evidence it was done. It should have been turned in and in the record within 7 days, but wasn’t, more education is needed.””

“It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by personnel record review and an interview with the Chief Compliance Officer which revealed issues with the agency’s ability to provide core services directly by hospice employees in a manner consistent with acceptable standards of practice in the following areas: Failure to ensure the core services of a spiritual counselor by a hospice employee; the Chaplain (Personnel Record 6) was hired on 10/18/2023 as a 1099 contracted employee {HCDT.2.I/L587}. The cumulative effect of this deficiency has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed in which a patient was live discharged revealed the agency did not ensure the patient signed discharge forms per agency policy. The Agency Policy titled “Discharge from Hospice Program Policy 0-125 Dated November 2021 stated in the relevant part “Procedure: 1. All necessary paperwork will be completed, including a signed revocation form. 5. The organization will inform the family both verbally and in writing, including a timeline for discontinuing services.” Clinical Record 11: The patient was discharged for extended prognosis on 08/27/2024. The clinical record did not contain evidence of the Notification of Medicare Non-Coverage Form being given to the patient or family. Clinical Record 12: The patient elected to revoke their hospice benefit on 11/02/2023. The clinical record did not contain evidence of the revocation form being given to the patient or family. An interview was conducted on 10/16/2024 with the Chief Compliance Officer and the Director of Nursing who agreed that the Notification of Medicare Non-Coverage and Revocation forms were not in the clinical records and had not been issued to the patients or families.”

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s: Well-being; Comfort; and Dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records it was revealed the agency did not ensure the initial comprehensive assessment included a review of the psychosocial and spiritual needs of the patient. Clinical Record 2: The patient elected the hospice benefit on 05/10/2023. The initial comprehensive assessment documented by the registered nurse did not include an assessment of the psychosocial or spiritual needs of the patient. There was documentation that the patient had declined the social worker and the chaplain services, therefore the clinical record did not have evidence that either of those disciplines had assessed the psychosocial or spiritual needs of the patient. In an interview with the Director of Nursing on 10/15/2024, she stated “I thought it was okay if they put a note they were declined.””

“It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure the patient’s individualized written plan of care included measurable outcomes. Clinical Record 2: The patient elected the hospice benefit on 05/10/2023 for the diagnosis of protein-calorie malnutrition. The Plan of Care dated 05/10/2023 included the following: “Nutrition Goal: Patient will have adequate food and fluids to maintain food and fluids to maintain comfort.” The plan of care did not describe adequate food and fluids or how these were measurable. Clinical Record 4: The patient elected the hospice benefit on 09/30/2024 for the diagnosis of malignant neoplasm of the pancreas. The Plan of Care dated 09/30/2024 included the following: “Cardiopulmonary Goal: Patient will verbalize increased comfort or decreased episodes of chest pain.” The Plan of Care did not provide measurable goals for the patient’s increased comfort or episodes of chest pain. Clinical Record 10: The patient elected the hospice benefit on 08/21/2024 for the diagnosis of atherosclerotic heart disease. The Plan of Care dated 08/21/2024 included the following: “Cardiopulmonary Goal: Will prevent potential alteration in cardiac status. Neuro: In 5-6 weeks patient will demonstrate stable mental status.” The Plan of Care did not describe the potential alteration in cardiac status or provide a measurable goal for stable mental status. An interview was conducted with the Director of Nursing on 10/15/2024 and she agreed the Plans of Care did not include measurable goals, she discussed several suggestions made that she could add to change the Plans of Care to make the goals measurable and individualized.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) home visits, with completed with a hospice aide, revealed the agency did not ensure that the hospice aide provided services included in the plan of care. Home Visit 1/Clinical Record 1: During the home visit, on 10/16/2024 with the hospice aide (Personnel Record 7), the aide was observed performing a sponge bath instead of a shower. The aide plan of care (dated 04/11/2023) included the following orders for the hospice aide “visit frequency of two times per week and the shower to be provided every visit.” During an interview with the Director of Nursing on 10/16/2024 it was determined the aide care plan had not been followed.”

“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. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide reported changes to a registered nurse. Clinical Record 7: The hospice aide care plan dated 09/27/2024 contained the following tasks to be completed every visit at a frequency of 2 times per week: oral care, shave, and range of motion. On the hospice aide visits dated 10/07/2024, 10/10/2024, and 10/14/2024 those tasks were marked “No”. The record lacked documentation the aide had notified the registered nurse the task(s) had not been completed as ordered in the plan of care. Clinical Record 10: The hospice aide care plan dated 08/21/2024 contained the following tasks to be completed every visit at a frequency of 2 times per week: oral care, foley care, nail care, ambulate, and toilet. On the hospice aide visits dated 09/23/2024, 10/07/2024, 10/10/2024, and 10/14/2024, those tasks were marked “No.” The record lacked documentation the aide had notified the registered nurse the task(s) had not been completed as ordered in the plan of care. A joint clinical record review and interview was conducted with the Director of Nursing and Chief Clinical Officer on 10/16/2024 during which time they agreed the aide did not complete the tasks as assigned on the care plans and there was no documentation of a report to a registered nurse included in the clinical records.”

“It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Counseling services, including spiritual counseling, bereavement counseling, dietary counseling, marriage and family therapy counseling, and mental health counseling. This standard was not met as evidenced by interview and personnel record review. In 1 of 9 (11%) personnel records reviewed it was revealed that the agency did not ensure that the care and services were consistent with the accepted standards of practice. On 10/15/2024, a review of the Spiritual Counselor’s employee file (Personnel Record 6) hired on 10/18/2023 revealed that the employee had signed a W9, making them a contracted employee. The Chief Compliance Officer was interviewed on 10/15/2024 regarding the W9 and stated, “the Spiritual Counselor worked per diem and often did 2–3-hour visits with the patients but had requested the W9 as she didn’t want taxes taken out.” He further stated that in 2023, before hiring her, the Agency had another “Spiritual Counselor who was a W4 employee, but that person had to return to the Philippines for an emergency.” On 10/15/2024, a review of the Spiritual Counselor’s employee file (Personnel Record 6) hired on 10/18/2023 revealed that the employee had signed a W9, making them a contracted employee. The Chief Compliance Officer was interviewed on 10/15/2024 regarding the W9 and stated “the Spiritual Counselor worked per diem and often did 2-3 hour visits with the patients but had requested the W9 as she didn’t want taxes taken out.” He further stated that in 2023, before hiring her, the Agency had another “Spiritual Counselor who was a W4 employee and that person had to return to the Philippines for an emergency.””

“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. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure 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. The Agency Policy titled “Clinical Record Review Policy 3-007 Dated November 2021” stated in the relevant part: “A. The timeliness of entries into the clinical record by all disciplines should be completed within seven (7) days after each visit. B. The compliance officer will regularly monitor the timeliness and accuracy of all clinical records.” Clinical Record 7: The plan of care dated 09/27/2024 ordered a skilled nursing visit frequency of 1 time per week. A clinical record review on 10/17/2024 revealed no skilled nursing visits documented week of 9/29/2024 or week of 10/6/2024. An interview was conducted on 10/17/2024 with the Chief Compliance Officer regarding the undocumented visits. He called the skilled nurse who had been scheduled to make the visits. She responded that the “visits had been made but she was working at her other job and hadn’t had time to enter them in the clinical record at this time.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, in which a discharge summary was required, revealed the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The patient was discharged for extended prognosis on 08/27/2024. The clinical record did not contain evidence of the discharge summary being forwarded to the patient’s attending physician. Clinical Record 12: The patient elected to revoke their hospice benefit on 11/02/2023. The clinical record did not contain evidence of the discharge summary being forwarded to the patient’s attending physician. A joint clinical record review and interview was conducted with the Director of Nursing and Chief Clinical Officer on 10/16/2024 during which time they agreed the discharge summaries had not been forwarded to the attending physician(s) for either of the live discharges.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed, in which a discharge summary was required, revealed the agency did not ensure the patient’s discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 11: The patient was discharged for extended prognosis on 08/27/2024. The discharge summary narrative section was blank and there was not other documented evidence the discharge summary included the summary of the hospice stay, including treatments, symptoms, and pain management. Clinical Record 12: The patient elected to revoke their hospice benefit on 11/02/2023. The discharge summary narrative section was blank and there was not other documented evidence the discharge summary included the summary of the hospice stay, including treatments, symptoms, and pain management. A joint clinical record review and interview was conducted with the Director of Nursing and Chief Clinical Officer on 10/16/2024 during which time they agreed the discharge summary had not been completed and the Director of Nursing stated she “was not aware of the regulation to add a narrative.””