Priority One Hospice

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical record reviewed revealed the agency did not ensure the registered nurse (RN) completed an updated comprehensive assessment no less frequently than every 15 calendar days. CLINICAL RECORD 1: The interdisciplinary group (IDG) plan of care (POC) dated 11/21/2024 for the certification period 11/21/2024 - 02/18/2025 and IDG POC dated 02/19/2025 for the certification period 02/19/2025 - 05/15/2025 had an nurse visit frequency of SN one (1) time per week and four (4) prn visits for sudden changes in clinical condition for both certification period. There was evidence of RN visits completed on 11/21/2024, 12/18/2024 (27 days), 01/15/2025 (25 days) 02/12/2025 (31 days) and 03/12/2025 (28 days). The record lacked evidence of a completed RN visit no less frequently than every 15 calendar days. CLINICAL RECORD 3: The IDG POC dated 01/01/2025 for the certification period 01/01/2025 - 03/31/2025 had a nurse visit frequency of SN two (2) times per week and three (3) prn visits for sudden changes in clinical condition. There was evidence of RN visits completed on 01/01/2025, 01/29/2025 (28 days), 02/26/2025 (28 days), and 03/19/2025(21 days). The record lacked evidence of a completed RN visit no less frequently than every 15 calendar days. CLINICAL RECORD 5: The IDG POC dated 01/21/2025 for the certification period 01/21/2025 - 04/20/25 had a nurse visit frequency of SN two (2) times per week and four (4) prn visits for sudden changes in clinical condition. There was evidence of RN visits completed on 01/21/2025, 02/20/2025 (30 days), and 03/19/2025 (27 days). The record lacked evidence of a completed RN visit no less frequently than every 15 calendar days. The Administrator/Director of Patient Care Services stated in an interview on 03/27/2025 that the agency did not ensure the RN completed a patient assessment no less frequently than every 15 calendar days.”

“It is required that a hospice aide provides services Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients that elected hospice aide services revealed that the agency did not ensure that the aide provided ordered tasks on the aide care plan. CLINICAL RECORD 4: The aide care plan dated 02/06/2025 did not include the task shampoo hair. The aide visit notes dated 03/05/2025 and 03/07/2025 stated in both visit note narratives, “applied shampoo to hair ....”. The aide performed a task that was not included in the aide care plan. The Administrator/Director of Patient Care Services stated in an interview on 03/27/2025 that the agency did not ensure that the aide provided services included on the aide care plan.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients that elected hospice aide services that required the aide to report changes in the patient medical needs to the registered nurse (RN) revealed the agency did not ensure the aide reported changes in the patient’s medical needs to the RN as the changes related to the aide care plan. CLINICAL RECORD 4: The aide care plan dated 02/06/2025 did not include the task shampoo hair.. The aide visit notes dated 03/05/2025 and 03/07/2025 stated in both visit note narratives, “applied shampoo to hair ....”. There was no documented evidence that the aide reported the shampooing of the patient’s hair that was not included on the aide plan of care. The Administrator/Director of Patient Care Services stated in an interview on 03/27/2025 that the agency did not ensure that the aide reported changes in the patient’s medical needs to the RN.”

“It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including 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 was not met, as evidenced by personnel record reviews, contract reviews, and interviews with the Administrator, which revealed that the hospice failed to ensure that the Hospice Medical Social Work services were substantially provided by hospice employees in a manner consistent with acceptable standards of practice. The agency failed to ensure that a qualified social worker provided medical social work services [HCDT.9.I/594]. 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. personnel record review and interview revealed the agency did not ensure that all core services were provided directly by hospice employees. The social worker is listed as contracted on the active personnel list.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes the following: EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 9 (11%) personnel records reviewed, it was revealed that the agency did not ensure that emergency preparedness training/education was provided at least every 2 years. Agency policy, Emergency Management Plan, stated in part, “The training is provided at least every two (2) years, unless more frequent training is necessary due to a significant update of the organization’s policies and procedures. All training will be documented, including the dates, participants and content, in the personnel record of staff, individuals under arrangement and volunteers, if applicable.” Personnel Record 9: The date of hire for this Volunteer was 01/21/2019. The personnel record for the volunteer lacked evidence of emergency preparedness training at least every 2 years, last documented training in the volunteer personnel record was for April 2022. During an interview with the Volunteer Coordinator, on 02/13/2025, she stated that she was unaware of this requirement but would be sure that her volunteers received the required education.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes the education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 9 (11%) personnel record review revealed the agency did not ensure infection control education be provided to the volunteer. Agency policy, Infection Control, stated in part, “Infection control in-services will be scheduled no less than annually. Attendance will be mandatory and will be documented. Records of in-service attendance will be maintained in the personnel file.” Personnel Record 9: The personnel record review for the Volunteer, hired on 01/21/2019, lacked evidence of annual infection control education. The personnel record contained infection control education for on-hire, 2020, 2021, and 2022; no yearly infection control education was documented for 2023 or 2024. During an interview with the Volunteer Coordinator on 02/13/2025, she stated she was unaware that the same requirements for employees were extended to volunteers. She stated that she is new to the position and will be sure to implement those requirements.”

“It is required that medical social services are provided by a qualified social worker. This standard was not met as evidenced by personnel record review, contract review, and interview. In 1 of 1 (100%) personnel record review of a Social Worker (SW), the agency did not ensure that a qualified social worker provided medical social services. Agency Contract: A contract for Social Work services was signed on 12/01/2014. The contract was for multiple social workers, however the hospice agency had one primary SW assigned that made the patient visits. The agency presented a personnel record for the primary SW which documented they were a Bachelor prepared Social Worker (BSW). The record included orientation. During an interview with the Administrator on 02/11/2025 she stated that they knew they needed a social worker but did not realize that the social worker required to be an employee instead of contracted. The Administrator reported that supervision for the contracted BSW was completed by a Licensed Master prepared Social Worker, who was also contracted. Before the end of the site visit the Administrator reported that three social workers had been hired as PRN (as needed) employees.”

“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; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 5 (60%) clinical records reviewed, it was revealed that the agency did not ensure hospice aide supervisory visits were conducted no less frequently than every 14 days. Agency policy, Hospice Aide Supervisory Visits, stated in part, “The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days.” CLINICAL RECORD 1: The patient elected the hospice benefit on 08/23/2024 with a diagnosis of End Stage Renal Failure. The plan of care dated 11/21/2024 to 02/18/2025 included orders for the hospice aide visits two times per week. The clinical record included documented aide supervisory visits on 11/05/2024 with the next one documented on 12/10/2024, 35 days later and 21 days outstanding. CLINICAL RECORD 2: The patient elected the hospice benefit on 11/01/2024 with a diagnosis of Malignant neoplasm of pancreas. The plans of care dated 11/01/2024 to 01/29/2025 and 01/30/2025 to 04/29/2025 included hospice aide visits two times per week. The clinical record included documented aide supervisory visits on 01/06/2025 with the next one documented on 02/05/2025, 30 days later and 16 days outstanding. CLINICAL RECORD 8: The patient elected the hospice benefit on 01/05/2024 with a diagnosis of End Stage Heart Failure. The plan of care dated 01/05/2024 to 04/03/2024 included orders for the hospice aide visits three times per week. The clinical record included documented aide supervisory visits on 02/21/2024 with the next one documented on 03/13/2024, 20 days later and 6 days outstanding. During an interview with the Administrator on 02/13/2025, she stated that they have been working on scheduling the aide supervisory visit within the required timeframe and that they will provide more education to the clinical staff.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. During a review of the volunteer program, the agency lacked evidence of ongoing recruitment and retention efforts. The last documented retention activity was 04/16/2016, and there was no documentation of retention activities. Agency policy, Volunteer Services, stated in part, “The Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds.” During an interview on 02/13/2025, the Volunteer Coordinator stated that she was unaware of this requirement but would implement it immediately. She also stated that they provide lunch for volunteers and celebrate their birthdays; they just have not been documenting it, but she will start. During a review of the volunteer program, the agency lacked evidence of ongoing recruitment and retention efforts. The last documented retention activity was 04/16/2016, and there was no documentation of retention activities.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed, it was revealed that the agency did not ensure the recertification was completed no later than 2 calendar days after the first day of each benefit period and no more than 15 days before the next benefit period begins. CLINICAL RECORD 3: The clinical record review lacked evidence of a written certification of terminal illness for benefit periods 09/22/2023 to 12/20/2023, 12/21/2023 to 03/19/2024, 03/20/2024 to 05/18/2024, 05/19/2024 to 07/17/2024, 07/18/2024 to 09/15/2024, 09/16/2024 to 11/14/2024, 11/15/2024 to 01/13/2025, and 01/14/2025 to 03/14/2025. The clinical record contained a verbal certification for each benefit period but not a written certification. During an interview with the Administrator on 02/12/2025, she stated that she thought the verbal certification was the required element, but she would contact the Medical Director immediately and obtain a written certification for each patient. During an interview with the Hospice Medical Director on 02/12/2025, she stated that she had been contacted and informed of the missing written certification of terminal illness, and she had completed one for the current benefit period.”