Vbk Hospice, Inc.

“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 and interview. In 2 of 2 (100%) clinical records reviewed, the agency did not ensure the nurse documented continuous assessment of the patient’s and family’s needs as required by agency policy. Agency policy No. 2-031-1 Ongoing Comprehensive Assessments, no date, required in part, “The nurse will assess the patient on each visit, for: A. Pain, including the origin, location, duration, severity, and relief measures. B. Secondary symptoms related to the terminal illness such as nausea, vomiting, and respiratory distress, and the patient’s response to medications and other interventions. C. Factors that alleviate or exacerbate physical symptoms. D. Current treatment related to the identified symptoms and the patient’s response. E. Vital signs appropriate to the patient’s condition. F. Breath sounds. G. Skin integrity. H. Bowel sounds, elimination (urinary and bowel). I. Mental status. J. Appetite/diet, nutritional status. K. Functional status. L. Safety/home environment. M. Patient and family/caregiver support. N. Spiritual issues. O. Additional psychosocial issues. P. Progress toward hospice goals and patient needs and problems. Q. Compliance with treatments and medication regimen. R. The need for an alternative setting or level of care.” Clinical Record 1: The patient elected the hospice benefit on 05/10/2024 with a diagnosis of Alzheimer’s disease. The plans of care for the benefit periods dated 05/10/2024 to 08/07/2024 and 08/08/2024 to 11/05/2024 included physician orders for the hospice nurse frequency of visits one time per week. Clinical record review completed on 08/19/2024 revealed the last nursing visit note was dated 08/09/2024. On 08/20/2024 the agency provided the site visitor with a document titled “flow sheet.” Review of the flow sheet document dated 08/16/2024, revealed the Registered Nurse had documented a nursing visit on the form. The flow sheet included documentation of the patient’s name, date, time, blood pressure, pulse rate, respiration rate, temperature, date of last bowel movement, pain level, current medication effective (yes or no), comments, patient signature, and signature/title of the nurse. The flow sheet did not include documentation of the elements of a nursing assessment as outlined in agency policy. Clinical Record 2: The patient elected the hospice benefit on 05/01/2024 with a diagnosis of malignant neoplasm of the endometrium. The plans of care for the benefit periods dated 05/01/2024 to 07/29/2024 and 07/30/2024 to 09/27/2024 included physician orders for the hospice nurse frequency of visits one time per week. Clinical record review completed on 08/19/2024 revealed the last nursing visit note was dated 08/02/2024. On 08/20/2024 the agency provided the site visitor with a document titled “flow sheet.” Review of the flow sheet document revealed the Registered Nurse documented nursing visits dated 08/08/2024 and 08/15/2024 on the form. The flow sheet included documentation of the patient’s name, date, time, blood pressure, pulse rate, respiration rate, temperature, date of last bowel movement, pain level, current medication effective (yes or no), comments, patient signature, and signature/title of the nurse. The flow sheet did not include documentation of the elements of a nursing assessment as outlined in agency policy. During an interview and record reviews on 08/20/2024, the Director of Patient Care Services (DPCS) and the Alternate Administrator confirmed the assessments documented on the paper “flow sheets” did not adhere to the agency’s policy and did not provide evidence that the patient and family needs had been assessed. The DPCS stated “we were having problems with the electronic medical record (EMR), so we used those forms.” When asked if there was additional documentation that would support all required areas of the assessment were completed. The DPCS stated “I wrote things down in a notebook but couldn’t add it since the EMR wasn’t working.” The Alternate Administrator explained further investigation into the issue with EMR revealed that on 08/10/2024 the clinical staff were unable to enter any items into the system and the EMR company was contacted. A letter from the EMR company dated 08/14/2024 was presented to the site visitor as evidence the EMR was not working. The letter reported that on 08/10/2024 the agency’s EMR was placed in “read only” mode. The Alternate Administrator and DPCS were asked; what was the agency’s policy/process for meeting the documentation requirements if the EMR system went down such as in a power outage or a cyberattack. The DPCS responded, “we just write it on paper.” The Alternate Administrator located a blank nursing assessment paper document, which contained required components, and stated these would be used effective immediately.”

“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. In 1 of 2 (50%) clinical records reviewed, the agency did not ensure the individualized plan of care included patient and family goals, and planned interventions based on problems identified during assessments. THIS IS A CONTINUING REQUIRED ACTION. Clinical Record 1: The patient elected the hospice benefit on 05/10/2024 with a diagnosis of Alzheimer’s disease. The plans of care for the benefit periods dated 05/10/2024 to 08/07/2024 and 08/08/2024 to 11/05/2024 included orders for the Chaplain to visit the patient once per month. The Chaplain documented on the spiritual care visit note dated 07/14/2024 “the patient’s faith is strong and [the patient’s] belief in God gives [the patient] purpose and meaning in life. Chaplain provided emotional and spiritual support through offering encouragement and validating their concerns and showing empathy to the patient’s condition. Chaplain will come and visit patient once a month to continue providing emotional and spiritual support.” The Chaplain documented on the spiritual care visit note dated 08/02/2024 “Chaplain provided emotional and spiritual support to the patient and [spouse] through attentive listening, validation, and empathy. Encouraging words about faith and hope were offered to provide them emotional and spiritual support.” The plan of care updates from 07/14/2024 to current, did not include problems, goals, or interventions that addressed the patient/family spiritual needs. During an interview and record review on 08/19/2024, the Alternate Administrator confirmed the plan of care did not include goals or interventions related to the spiritual needs of the patient/family.”

“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 document review, clinical record review, and interview. In 2 of 2 (100%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide documented services provided as required by agency policy. Agency policy No. 5-006.1 Entries into the Clinical Record, no date, required in part, “Hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided.” Clinical Record 1: The patient elected the hospice benefit on 05/10/2024 with a diagnosis of Alzheimer’s disease. The plans of care for the benefit periods dated 05/10/2024 to 08/07/2024 and 08/08/2024 to 11/05/2024 included physician orders for the hospice aide frequency of visits one time per week. The aide plan of care assigned the aide to provide the tasks of bathing, dressing, and informing the Registered Nurse (RN) if the patient had pain or skin changes. Clinical record review revealed the last aide visit documented in the electronic medical record [EMR] was dated 06/26/2024 and no further aide visit notes were included in the record after 06/26/2024. During a review of findings on 08/19/2024, the Alternate Administrator confirmed that the aide visits were not entered electronically into the system and there were no paper documents of aide visits that had been completed and uploaded into the clinical record. The Alternate Administrator stated the Director of Patient Care Services had reported that the aides were using paper documentation but “had not brought them [the aide visit notes] into the office.” On 08/20/2024 the agency provided documents titled “route sheets.” The route sheets dated 07/17/2024, 07/24/2024, 07/31/2024, 08/07/2024, and 08/14/2024 included documentation by the hospice aide of the date, start and end times of the visit, patient name, and patient/caregiver signature. The route sheets did not include documentation of what tasks or services the hospice aide had provided during the visits. Clinical Record 2: The patient elected the hospice benefit on 05/01/2024 with a diagnosis of malignant neoplasm of the endometrium. The plans of care for the benefit periods dated 05/01/2024 to 07/29/2024 and 07/30/2024 to 09/27/2024 included physician orders for the hospice aide frequency of visit one time per week. The aide plan of care assigned the aide to provide the tasks of showering, dressing, and informing the RN if the patient had pain or skin changes. Clinical record review revealed the last aide visit documented in the EMR was dated 07/13/2024. The route sheets dated 07/17/2024, 07/24/2024, 07/31/2024, 08/07/2024, and 08/14/2024 included documentation by the hospice aide of the date, start and end times of the visit, patient name, and patient/caregiver signature. The route sheets did not include documentation of what tasks or services the hospice aide had provided during the visits. During an interview on 08/20/2024 the Director of Patient Care Services (DPCS) confirmed that the documentation on the “route sheets” did not include documentation of the aide services provided, changes in patient’s needs, and notifications to the RN. The DPCS reported she was aware the aide was not documenting in the EMR and thought the paper “route sheets” would suffice.”

“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 needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse (RN) assessed the quality of care and services provided by the hospice aide during supervisory visits. Clinical Record 1: The patient elected the hospice benefit on 05/10/2024 with a diagnosis of Alzheimer’s disease. The plans of care for the benefit periods dated 05/10/2024 to 08/07/2024 and 08/08/2024 to 11/05/2024 included physician orders for the hospice aide frequency of visits one time per week. The aide plan of care assigned the aide to provide the tasks of bathing, dressing, and informing the Registered Nurse (RN) if the patient had pain or skin changes. Clinical record review revealed the last aide visit documented in the electronic medical record [EMR] was dated 06/26/2024 and no further aide visit notes were included in the record after 06/26/2024. During a review of findings on 08/19/2024, the Alternate Administrator confirmed that the aide visits were not entered electronically into the system and there were no paper documents of aide visits that had been completed and uploaded into the clinical record. The Alternate Administrator stated the Director of Patient Care Services (DPCS) had reported that the aides were using paper documentation but “had not brought them [the aide visit notes] into the office.” On 08/20/2024 the agency provided documents titled “route sheets.” The route sheets dated 07/17/2024, 07/24/2024, 07/31/2024, 08/07/2024, and 08/14/2024 included documentation by the hospice aide of the date, start and end times of the visit, patient name, and patient/caregiver signature. The route sheets did not include documentation of what tasks or services the hospice aide had provided during the visits. Clinical Record 2: The patient elected the hospice benefit on 05/01/2024 with a diagnosis of malignant neoplasm of the endometrium. The plans of care for the benefit periods dated 05/01/2024 to 07/29/2024 and 07/30/2024 to 09/27/2024 included physician orders for the hospice aide frequency of visit one time per week. The aide plan of care assigned the aide to provide the tasks of showering, dressing, and informing the RN if the patient had pain or skin changes. Clinical record review revealed the last aide visit documented in the EMR was dated 07/13/2024. The route sheets dated 07/17/2024, 07/24/2024, 07/31/2024, 08/07/2024, and 08/14/2024 included documentation by the hospice aide of the date, start and end times of the visit, patient name, and patient/caregiver signature. The route sheets did not include documentation of what tasks or services the hospice aide had provided during the visits. On 08/20/2024 the DPCS and Alternate Administrator were interviewed and asked how the agency was able to determine if the hospice aides were providing services in accordance with the plan of care when there is no documentation of what cares the aide provided at the aide visits. The DPCS stated, “we ask the patient if they are happy with the care” during the supervisory visit. During aide supervisory visits, the RN could not assess if the aide provided services as ordered by the IDG when the aide did not document the services provided on the aide visit note. Standards Operations Manual, Appendix M, Interpretive Guidelines §418.76(h)(1)(i) stated in part, “In addition to ensuring that hospice aides furnish the care identified in the plan of care, RN supervisors must assess the adequacy of the aide services in relationship to the needs of the patient and family.””

“It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by document review and interviews with the Director of Nursing, which revealed that the governing body failed to ensure the agency implemented the emergency preparedness program and emergency preparedness (EP) plan in the following areas: Failure to ensure a risk assessment using an all-hazards approach was developed [HSEP.2.D/E6]; Failure to ensure emergency preparedness plan was reviewed and updated every two years [HSEP.2.D/E4]; Failure to ensure emergency preparedness policies and procedures were reviewed and updated at least every two years [HSEP.3.D/E13]; Failure to ensure emergency preparedness communication plan was reviewed and updated at least every two years [HSEP.4.D/E29]; Failure to ensure the emergency preparedness training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan and was reviewed and updated at least every two years [HSEP.5.D/E36]; and Failure to ensure the emergency preparedness plan was tested annually [HSEP.6.I/E39]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“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 of participation was not met as evidenced by review of clinical records, interviews, and review of findings with the Director of Nursing which revealed the following issues with the development and implementation of the patients’ interdisciplinary care plans: Failure to ensure hospice care and services provided to patients and families followed the individualized plan of care [HCPC.19.I/L543]; Failure to ensure the individualized plan of care included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments [HCPC.21.I/L545]; and Failure to ensure the individualized plan of care was reviewed, revised, and documented by the Interdisciplinary Group [IDG] no less frequently than every 15 calendar days [HCPC.22.I/L552]. 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 418.56: Interdisciplinary Group, Care Planning, and Coordination of 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 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. The hospice may contract for physician services per standard HCDT 5.I in this chapter. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by personnel record review and interview. In 3 of 5 (60%) personnel records reviewed of core services including nursing services, medical social services, and spiritual counseling, the agency did not ensure core services were substantially provided directly by hospice employees. Personnel Record 5: Registered Nurse (RN) date of hire 03/25/2024. Personnel record review revealed the nurse completed a W-9 form, indicating the nurse was an independent contractor with the agency. The personnel record contained no documented evidence that the nurse was issued a W-4 form which would indicate the nurse was employed by the hospice. During a review of the personnel record and interview on 07/10/2024, the Director of Nursing confirmed the RN was not issued a W-4 form and was not a direct employee of the hospice. Personnel Record 6: Medical Social Worker (MSW) date of hire 11/02/2021. Personnel record review revealed the MSW completed a W-9 form, indicating the MSW was an independent contractor with the agency. The personnel record contained no documented evidence that the MSW was issued a W-4 form which would indicate the MSW was employed by the hospice. During a review of the personnel record and interview on 07/10/2024, the Director of Nursing confirmed the MSW was not issued a W-4 form and was not a direct employee of the hospice. Personnel Record 7: Chaplain/Spiritual Counselor date of hire 04/16/2022. Personnel record review revealed the Chaplain completed a W-9 form, indicating the Chaplain was an independent contractor with the agency. The personnel record contained no documented evidence that the Chaplain was issued a W-4 form which would indicate the Chaplain was employed by the hospice. During a review of the personnel record and interview on 07/10/2024, the Director of Nursing confirmed the Chaplain was not issued a W-4 form and was not a direct employee of the hospice. The cumulative effect of this deficient practice 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 short-term inpatient care is available for pain control, symptom management, and respite purposes. The hospice has criteria for general inpatient care and for respite admissions. Inpatient care is provided in a participating Medicare or Medicaid facility. THIS IS A CMS CONDITION LEVEL CITATION OF DEFICIENCY. This Condition of Participation was not met as evidenced by review of agency documents, interviews, and review of findings with the Director of Nursing which revealed issues with the agency’s ability to provide patients with short-term inpatient care for pain control, symptom management, and respite care in the following areas: Failure to ensure a contract with an inpatient facility for inpatient care related to pain control and symptom management [HSIC.2.I/L707]; and Failure to ensure a contract with an inpatient facility for respite care [HSIC.3.I/L708]. 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 418.108: Short-term Inpatient Care. 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 and its staff operate and provide care and services: in compliance with local, state, and federal law and regulation related to the health and safety of patients and as a licensed entity if state or local law provides for hospice licensing. THIS IS A CMS CONDITION LEVEL CITATION OF DEFICIENCY. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure hospice care and services were provided to patients within the agency’s state licensed service area. The site visitor requested a copy of the agency’s state license to verify the counties the agency was licensed to provide hospice care and services within the state. The agency provided a copy of the state letter from 2021 and was unable to provide a more recent letter from the state to verify the agency’s service area. Clinical Record 2/Home Visit 4: The patient elected the hospice benefit on 05/06/2024. Review of the clinical record review revealed the patient’s home address was approximately 231 miles from the agency’s parent office and outside the agency’s state licensed service area. The patient’s home address was confirmed during the home visit observation with the Hospice Aide (Personnel Record 11). During the home visit observation, the patient’s hospice folder and consent form were reviewed, and it was noted that the hospice folder and consent form signed by the patient at the start of care had the name of another hospice agency. During a joint clinical record review and interview on 07/12/2024, the Director of Nursing (DON) confirmed that the patient lived outside the agency’s state licensed service area. The DON stated that a discussion had occurred with the Administrator about increasing the service area but was unaware if the process had been started. The cumulative effect of this deficient practice has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.116: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency. Upon reviewing the agency license and counties serviced, the documentation lacked evidence of a letter from the state verifying which counties the agency was licensed to provide services. Los Angeles County, Orange County, Riverside County, San Bernardino County, and Ventura County were listed at the last verification in 2021.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure that the EP plan was reviewed and updated every two years. Review of the agency’s emergency preparedness (EP) plan revealed no documented evidence that the EP plan was reviewed for 2022, 2023, and 2024. During an interview on 07/09/2024, the Director of Nursing confirmed that the EP plan was not reviewed and updated at least every two (2) years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of the emergency plan reviewed for 2022, 2023, and 2024.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of: Power failures, Natural or man-made disasters, Emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk, and Other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by document review and interview. The hospice did not ensure a risk assessment using an all-hazards approach was developed. Review of the agency’s emergency preparedness (EP) plan and documentation revealed no documented evidence of a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for 2022, 2023, and 2024. During an interview on 07/09/2024, the Director of Nursing confirmed that a documented hospice-based and community-based risk assessment was not completed every two years using an “all-hazards” approach specific to the geography and population served. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for 2022, 2023, and 2024.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. Policies and procedures are reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure emergency preparedness policies and procedures were reviewed and updated at least every two years. Review of the agency’s emergency preparedness (EP) plan revealed no documented evidence that the emergency preparedness (EP) policies and procedures were reviewed and updated at least every two (2) years. During an interview on 07/09/2024, the Director of Nursing confirmed that the agency’s EP policies and procedures were not reviewed and updated at least every two years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan were reviewed and updated at least every two (2) years.”

“It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan, including all contact information, is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure the emergency preparedness (EP) communication plan was reviewed and updated at least every two years. Review of the emergency preparedness communication plan, including all contact information, revealed no documented evidence that the EP communication plan was reviewed and updated at least every two years. During an interview on 07/09/2024, the Director of Nursing confirmed that the EP communication plan, including all contact information, was not reviewed and updated at least every two years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) communication plan, including all contact information, was reviewed and updated at least every two (2) years.”

“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 training program is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure the emergency preparedness training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan and was reviewed and updated at least every two years. Review of the emergency preparedness plan and documents revealed no documented evidence that the emergency preparedness training program was based on the agency’s emergency preparedness (EP) plan, EP risk assessment, EP policies and procedures, and the EP communication plan. There was no documented evidence that the agency completed a risk assessment for 2022, 2023, and 2024. The documentation did not include evidence that the agency’s EP training program was reviewed and updated for 2022, 2023, and 2024. During an interview on 07/09/2024, the Director of Nursing confirmed that a documented emergency preparedness training program was not based on a current risk assessment and was not reviewed and updated at least every two years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for 2022, 2023, and 2024. The documentation lacked evidence that the training program was updated for 2022, 2023, and 2024.”

“It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to, a second full-scale exercise that is community-based or a facility-based functional exercise, or a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure that the emergency preparedness (EP) plan was tested annually. Review of the agency’s EP plan revealed no documented evidence that the emergency preparedness plan was tested annually, including participation in a full-scale exercise that is community-based every two (2) years and conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. During an interview on 07/09/2024, the Director of Nursing confirmed that the EP plan was not tested annually, including participation in a full-scale exercise that is community-based every two (2) years and an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness plan was tested annually, including participation in a full-scale exercise that is community-based every two (2) years and conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted.”

“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, 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, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure a medication reconciliation was completed and medications were updated to the medication profile. Home Visit 2/Clinical Record 1: The patient elected the hospice benefit on 05/10/2024. Review of the medication profile printed on 07/09/2024 revealed the patient was prescribed Humulin N Kwik Pen 100u/ml, 22 units SQ [subcutaneous] twice daily, and Metformin Hydrochloride 1000mg one tab twice daily. During the home visit observation with the Hospice Aide (Personnel Record 8), review of the patient’s home medications revealed the patient was taking Humulin N Kwik Pen 100u/ml, 22 units SQ in the AM and 24 units SQ in the PM, Metformin Hydrochloride 1000mg two tabs twice daily, dispensed 06/11/2024, Hydrocodone/APAP 5/325mg one tablet every six hours, no more than four in a day, dispensed 06/15/2023, and Hydrochlorothiazide 12.5mg one tab daily, dispensed 06/11/2024. The patient stated that he/she had been taking Humulin N at this dosage since February 2024, Hydrocodone/APAP for “a couple of years,” Metformin Hydrochloride at this dosage, and Hydrochlorothiazide for approximately eight years. There was no documented evidence in the clinical record that the Humulin N Kwik Pen and the Metformin Hydrochloride dosages had been updated on the hospice medication profile and no documented evidence that Hydrocodone/APAP, and Hydrochlorothiazide were included on the hospice medication profile. Home Visit 4/Clinical Record 2: The patient elected the hospice benefit on 05/06/2024. During the home visit observation with the Licensed Vocational Nurse (Personnel Record 11), review of the patient’s home medications revealed the patient was taking Prochlorperazine 10mg every six hours as needed for nausea and vomiting, dispensed 05/14/2024 and Ondansetron 8mg every eight hours as needed for nausea and vomiting, dispensed on 05/14/2024. The patient stated that he/she takes these medications when he/she receives chemotherapy. Prochlorperazine and Ondansetron were not included on the hospice medication profile and there was no documented evidence in the clinical record that the medications were included in the medication review. During a joint review of clinical records and interview on 07/12/2024, the Director of Nursing confirmed that there was no documented evidence that the medications were updated to the medication profiles and included in the medication review.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcome, reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires, no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure an assessment update was completed no less frequently than every 15 days. Clinical Record 2: The patient elected the hospice benefit on 05/06/2024. The plan of care dated 05/06/2024 included an order for “Frequency Licensed Vocational Nurse (LVN) frequency was one visit every two weeks and one PRN visit, and Registered Nurse (RN) frequency was one visit every two weeks and one PRN visit.” Clinical record review revealed the LVN provided nursing visits on 05/13/2024, 06/01/2024, 06/14/2024, and 07/02/2024 and the RN provided nursing visits with updated assessments on 05/20/2024, 06/05/2024, and 06/20/2024. The clinical record contained no documented evidence that the RN completed a nursing visit with updated assessment for the week of 07/01/2024 to 07/07/2024. During a joint clinical record review and interview on 07/10/2024, the Director of Nursing confirmed the record did not include an updated assessment by the RN for the week of 07/01/2024.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, 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 clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure hospice care and services provided to patients and families followed the individualized plan of care. Clinical Record 1: The patient elected the hospice benefit on 05/10/2024. The plan of care dated 05/10/2024 and the updated plans of care dated 05/15/2024 and 05/29/2024 included an order for “Frequency Spiritual Care one time per month and one prn [as needed] visit.” Clinical record review revealed no documented evidence that the Spiritual Counselor provided a spiritual care visit to the patient in May 2024. The plan of care dated 05/10/2024 and the updated plans of care dated 05/15/2024, 05/29/2024, 06/12/2024, and 06/26/2024 included an order for “Frequency Medical Social Worker (MSW) one time per month and one prn visit.” Clinical record review revealed no documented evidence that the MSW provided social service visits for May and June 2024. Clinical Record 2: The patient elected the hospice benefit on 05/06/2024. The plan of care dated 05/06/2024 and the updated plans of care dated 05/15/2024 and 05/29/2024 included an order for “Frequency Spiritual Care one time per month and one prn visit.” Clinical record review revealed no documented evidence that the Spiritual Counselor provided a spiritual care visit to the patient in May 2024. The plan of care also included orders for the Licensed Vocational Nurse (LVN) frequency one visit every two weeks and one PRN visit, and the Registered Nurse (RN) frequency was one visit every two weeks and one PRN visit. Clinical record review revealed the LPN provided nursing visits on 05/13/2024, 06/01/2024, 06/14/2024, and 07/02/2024 and the RN provided nursing visits on 05/20/2024, 06/05/2024, and 06/20/2024. The clinical record did not include an LPN visit for the week of 06/24/2024 to 06/30/2024 or an RN visit for the week of 07/01/2024 to 07/07/2024. The plan of care dated 05/06/2024 and the updated plans of care dated 05/15/2024, 05/29/2024, 06/12/2024, and 06/26/2024 included an order for “Frequency Medical Social Worker (MSW) one time per month and one prn visit.” Clinical record review revealed no documented evidence that the Medical Social Worker provided social service visits for May and June 2024. Clinical Record 3: The patient elected the hospice benefit on 05/01/2024. The plan of care dated 05/01/2024 and the updated plans of care dated 05/01/2024, 05/15/2024, and 05/29/2024 included an order for “Frequency Spiritual Care one time per month and one prn visit.” Clinical record review revealed no documented evidence that the Spiritual Counselor provided a spiritual care visit to the patient in May 2024. The updated plans of care dated 05/15/2024, 05/29/2024, 06/12/2024, and 06/26/2024 included an order for “Frequency Medical Social Worker (MSW) one time per month and one prn visit.” Clinical record review revealed no documented evidence that the Medical Social Worker provided social service visits for May and June 2024. Clinical Record 4: The patient elected the hospice benefit on 04/29/2024. The plan of care dated 04/29/2024 and the updated plans of care dated 05/01/2024, 05/15/2024, and 05/29/2024 included an order for “Frequency Spiritual Care one time per month and one prn visit.” Clinical record review revealed no documented evidence that the Spiritual Counselor provided a spiritual care visit to the patient in May 2024. The plan of care dated 04/29/2024 and the updated plans of care dated 05/01/2024, 05/15/2024, 05/29/2024, 06/12/2024, and 06/26/2024 included an order for “Frequency Medical Social Worker (MSW) one time per month and one prn visit.” Clinical record review revealed no documented evidence that the Medical Social Worker provided social service visits for May and June 2024. Clinical Record 8: The patient elected the hospice benefit on 08/08/2023. The plan of care dated 08/08/2023 and the updated plans of care dated 08/23/2023, 09/06/2023, 09/20/2023, 10/04/2023, 10/18/2023, 11/01/2023, 11/01/2023, 11/15/2023, 12/06/2023, 12/20/2023, 1/3/2024, and 1/17/2024 included an order for “Frequency Spiritual Counselor one visit per month and one prn visit.” Clinical record review revealed no documented evidence that the Spiritual Counselor provided spiritual care visits to the patient from 08/08/2023 to 01/29/2024. The plan of care dated 08/08/2023 and the updated plans of care dated 08/23/2023, 09/06/2023, 09/20/2023, 10/04/2023, 10/18/2023, 11/01/2023, 11/01/2023, 11/15/2023, 12/06/2023, 12/20/2023, 1/3/2024, and 1/17/2024 included an order for “Frequency Medical Social Worker (MSW) one time per month and one prn visit.” Clinical record review revealed no documented evidence that the Medical Social Worker provided social service visits for September, October, and December 2023. Clinical Record 14: The patient elected the hospice benefit on 11/08/2023. The updated plans of care dated 12/20/2023, 01/03/2024, and 01/17/2024 included an order for “Frequency Licensed Vocational Nurse (LVN) frequency was one visit every two weeks and one PRN visit, and Registered Nurse (RN) frequency was one visit every two weeks and one PRN visit.” Clinical record review revealed the RN provided nursing visits on 12/20/2023 and 01/30/2024. The clinical record did not include an RN visit for the week of 01/01/2024 to 01/07/2024 and 01/15/2024 to 01/21/2024. Clinical Record 17: The patient elected the hospice benefit on 04/23/2024. The plan of care dated 04/23/2024 and the updated plans of care dated 05/01/2024, 05/15/2024, and 05/29/2024 included an order for “Frequency Medical Social Worker (MSW) one time per month and one prn visit.” Clinical record review revealed no documented evidence that the Medical Social Worker provided social service visits for May and June 2024. During a joint clinical record review and interview on 07/12/2024, the Director of Nursing confirmed that spiritual counseling services, nursing services, and medical social services were not provided as ordered on the patients’ plans of care.”

“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 clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 05/10/2024. The patient’s primary hospice diagnosis was Alzheimer’s disease with a comorbidity of diabetes mellitus type 2. The nursing assessment dated 05/10/2024 included documentation that the patient had confusion, sharp continuous pain in both knees with an intensity of 6/10, bladder and bowel incontinence, constipation, aspiration precautions, and generalized weakness. The medication profile included orders for Jardiance [medication used to treat cardiovascular disease associated with diabetes mellitus] 25mg once daily and Metformin Hydrochloride [medication used to treat diabetes mellitus type 2] 850mg three times a day. The plan of care dated 05/10/2024 to 08/07/2024 did not include problems, interventions, and goals for memory loss, pain, risk for skin breakdown, constipation, aspiration, risk for falls, hyperglycemia, and hypoglycemia. Clinical Record 2: The patient elected the hospice benefit on 05/06/2024. The primary hospice diagnosis was malignant neoplasm of the unspecified ovary. The nursing assessment dated 05/06/2024 included documentation that the patient had constipation, bladder and bowel incontinence, weakness, and a moderate fall risk. The plan of care dated 05/06/2024 to 08/03/2024 did not include problems, interventions, and goals for constipation, risk for skin breakdown associated with bladder and bowel incontinence, and risk for falls. Clinical Record 3: The patient elected the hospice benefit on 05/01/2024. The primary hospice diagnosis was malignant neoplasm of the endometrium with comorbidities of hypertension and diabetes mellitus type 2. The nursing assessment dated 05/01/2024 included documentation that the patient had shortness of breath with ambulation and activities of daily living, aspiration precautions, bladder and bowel incontinence, and moderate fall risk. The medication profile included orders for Glipizide 10mg, two tablets twice a day, Humulin N [insulin prescribed to lower blood sugar levels] Kwik Pen 100unit/ml give 22u twice daily, and Metformin Hydrochloride [medication used to treat diabetes mellitus type 2] 1000mg twice a day. The plan of care dated 05/01/2024 to 07/29/2024 did not include problems, interventions, and goals for dyspnea/shortness of breath, risk for skin breakdown, aspiration, risk for falls, hyperglycemia, and hypoglycemia. Clinical Record 5: The patient elected the hospice benefit on 02/19/2024. The primary hospice diagnosis was atherosclerotic heart disease of the native coronary artery without angina pectoris. The nursing assessment dated 02/19/2024 included documentation that the patient had a high risk for skin impairment and a history of diabetes. The medication profile included orders for Glipizide 5mg twice daily and Jardiance [medication used to treat cardiovascular disease associated with diabetes mellitus] 25mg daily. The plan of care dated 02/19/2024 to 05/19/2024 did not include problems, interventions, and goals for risk for skin breakdown, hyperglycemia, and hypoglycemia. Clinical Record 6: The patient elected the hospice benefit on 10/17/2023. The primary hospice diagnosis was hypertensive heart disease with heart failure with comorbidities of hypertension, benign prostatic hyperplasia, and asthma. The nursing assessment dated 10/17/2023 included documentation that the patient had frequent chest pain, mild dyspnea, 2+ edema to both feet, wheezing on auscultation, constipation, incontinence of the bladder, and moderate fall risk. The plan of care dated 10/17/2023 to 01/15/2024 lacked problems, interventions, and goals for risk for chest pain, dyspnea/shortness of breath, abnormal breath sounds, edema, the risk for skin breakdown, constipation, and fall risk. During a joint review of the records and interview on 07/12/2024, the Director of Nursing confirmed the plans of care did not include problems, goals, and interventions for the problems identified in the nursing assessments.”

“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 1 of 19 (5%) clinical records reviewed, the agency did not ensure the individualized plan of care was reviewed, revised, and documented by the Interdisciplinary Group [IDG] no less frequently than every 15 calendar days. Clinical Record 17: The patient elected the hospice benefit on 04/23/2024. The clinical record contained no documented evidence that the IDG reviewed or revised the patient’s plan of care from 05/01/2024 to 05/29/2024. During a joint clinical record review and interview on 07/12/2024, the Director of Nursing confirmed there was no documented evidence that the IDG met to review the Plan of Care no less frequently than every 15 calendar days.”

“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 is evaluated annually. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. This standard was not met as evidenced by document review and interview. The agency did not ensure there was documentary evidence of its quality assessment and performance improvement program. Review of the agency’s quality assessment and performance improvement (QAPI) program revealed the documents labeled “Agendas” did not include dates and signatures and there was no documented evidence that the hospice governing body evaluated the program annually. During an interview on 07/12/2024, the Director of Nursing confirmed that the QAPI program did not include documentation that the hospice governing body evaluated the program annually. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documents labeled “Agendas” lacked dates and signatures. The documentation lacked evidence that the hospice governing body evaluated the program annually.”

“It is required that one or more individual(s) is appointed by the governance as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview. The agency did not ensure the governing body appointed an individual responsible for operating the QAPI program. Review of the agency’s quality assessment and performance improvement program and documentation revealed no documented evidence that the agency’s governing body had appointed one or more individual(s) to be responsible for operating the QAPI program. During an interview on 07/12/2024, the Director of Nursing confirmed that the QAPI program did not include documentation to show who was appointed by the governance as responsible for operating the QAPI program. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence of one or more individual(s) is appointed by the governance as responsible for operating the QAPI program.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy No. 6-006 Hand Hygiene, not dated, stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: after removing gloves.” Home Visit 2: During the home visit observation with the Hospice Aide (HA) (Personnel Record 8), the HA was observed to remove the gloves and did not wash or decontaminate hands. Home Visit 4: During the home visit observation with the Licensed Vocational Nurse (LVN) (Personnel Record 11), the LVN was observed to remove gloves and then was observed to use the phone, and handle medication bottles without washing or decontaminating hands. During a review of observations and interview on 07/12/2024, the Director of Nursing agreed staff did not follow the agency’s hand hygiene policy.”

“It is required that the infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by personnel record review and interview. In 2 of 12 (17%) personnel records reviewed, the agency did not ensure staff received infection control education. Personnel Record 6: The Medical Social Worker (MSW) date of hire 11/02/2021. Review of the personnel record revealed no documented evidence that the MSW received infection control education for 2022 and 2023. Personnel Record 7: The Chaplain/Bereavement Coordinator date of hire 04/16/2022. Review of the personnel record revealed no documented evidence that the Chaplain/Bereavement Coordinator received infection control education for 2023. During a joint record review and interview on 07/12/2024, the Director of Nursing confirmed that the personnel records did not include documentation of infection control education.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. This standard was not met as evidenced by personnel record review and interview. In 1 of 2 (50%) hospice aide personnel records reviewed, the agency did not ensure the aide competency evaluation was completed prior to the aide providing hospice aide services. Personnel Record 8: Hospice Aide date of hire 10/01/2022. Personnel record review revealed the Director of Nursing (DON) signed the skills and competency evaluation form on 10/01/2022, but the form was incomplete. The DON stated that the aide was not observed for skills and competency on that date, but a Registered Nurse did observe the Hospice Aide in June 2023. There was no documented evidence in the personnel record that the aide competencies were assessed at the time of hire. During a joint record review and interview on 07/10/2024, the Director of Nursing confirmed the personnel record did not include a competency assessment for the aide at the time of hire.”

“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 and interview. In 2 of 19 (11%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 05/01/2024. Clinical record review revealed a physician order dated 05/01/2024 ordered “HA [hospice aide] frequency of visit: Once a week to assist patient with personal care, ADLs [activities of daily living] and assistance as assigned by the RN [Registered Nurse] Supervisor Plan of Care for the entire benefit period of 05/01/24-07/29/24.” The clinical record contained no documented evidence that the Hospice Aide provided visits for the weeks of 05/01/2024 to 05/05/2024, 05/06/2024 to 05/12/2024, 05/13/2024 to 05/19/2024, 05/20/2024 to 05/26/2024, 05/27/2024 to 06/02/2024, 06/03/2024 to 06/09/2024, 06/10/2024 to 06/16/2024, 06/17/2024 to 06/23/2024, 06/24/2024 to 06/30/2024, and 07/01/2024 to 07/07/2024. Clinical Record 13: The patient elected the hospice benefit on 02/21/2024. The plan of care dated 02/21/2024 and the updated plan of care dated 03/06/2024 included an order for “Frequency Hospice Aide one time per week.” The clinical record contained no documented evidence that the Hospice Aide provided visits for the weeks of 02/21/2024 to 02/25/2024, 02/26/2024 to 03/03/2024, and 03/04/2024 to 03/10/2024. During a joint clinical record review and interview on 07/12/2024, the Director of Nursing confirmed that the records lacked evidence of documented hospice aide visits as ordered by the Interdisciplinary Group.”

“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. The agency did not ensure documentation of the volunteer program included evidence of efforts to retain volunteers. A review of the agency’s volunteer program and documentation revealed no documented evidence of efforts to retain volunteers. During an interview on 07/09/2024, the Director of Nursing confirmed that the retention efforts were not documented from January 2024 through July 2024. The Director of Nursing stated that they “focused on patient care more than volunteers.” Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers.”

“It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator is an employee of the organization, informs the governing body about ongoing operations, including patient care delivery issues and QAPI [quality assessment performance improvement] activities, and has the education and experience as required by the governing body. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document review and interview. The agency did not ensure documentation that the administrator was appointed by the governing body. Review of the governing body appointments and documentation revealed no documented evidence that the administrator was appointed by the governing body. During a joint governing body document review and interview on 07/12/2024, the Director of Nursing confirmed that the agency had no documentation of the governing body’s appointment of the administrator. Upon reviewing the governing body appointments, the documentation lacked evidence for an appointment for the administrator.”

“It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation, provision of care and services, and fiscal operations. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed, the hospice’s governance did not ensure hospice care and services were provided to patients within the agency’s state licensed service area. Upon reviewing the agency’s license and counties serviced, the documentation did not include evidence of a letter from the state verifying which counties the agency was licensed to provide services. The agency provided a letter dated 2021 which included the agency’s service area with counties licensed to provide services. Clinical Record 2/Home Visit 4: The patient elected the hospice benefit on 05/06/2024. Review of the clinical record review revealed the patient’s home address was approximately 231 miles from the agency’s office and outside the agency’s state licensed service area. The patient’s home address was confirmed during the home visit observation with the Hospice Aide (Personnel Record 11). During a joint clinical record review and interview on 07/12/2024, the Director of Nursing (DON) confirmed that the patient lived outside the state licensed service area. The DON stated that a discussion had occurred with the Administrator about increasing the service area but was unaware if the process had been started. Upon reviewing the agency license and counties serviced, the documentation lacked evidence of a letter from the state verifying which counties the agency was licensed to provide services. Los Angeles County, Orange County, Riverside County, San Bernardino County, and Ventura County were listed at the last verification in 2021.”

“It is required that a hospice may contract for durable medical equipment services with a Medicare-certified DME point-of-service (POS) supplier that meets the CMS DMEPOS Supplier Quality and Accreditation standards and has a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. This standard was not met as evidenced by document review and interview. The agency did not ensure the contracted DMEPOS supplier was accredited by a recognized accreditation organization. Review of the agency’s contract for durable medical equipment services with a Medicare-certified DME point-of-service (POS) supplier did not include documented evidence of a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. During a joint review of the contract documents and interview on 07/12/2024, the Director of Nursing (DON) confirmed that the contract for durable medical equipment did not contain a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. The DON stated that the DME agency had been contacted and asked to provide an updated letter verifying accreditation without success. Upon reviewing the contract for durable medical equipment services with a Medicare-certified DME point-of-service (POS) supplier, the documentation lacked evidence of a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization.”

“It is required that hospice inpatient care for pain control and symptom management is provided in one of the following: a Medicare-certified hospital or a skilled-nursing facility that also meets the standards specified in §418.110(b) (requiring 24-hour nursing care) and §418.110(f) (regarding home-like patient areas). This standard was not met as evidenced by document review and interview. The hospice did not ensure inpatient care for pain control and symptom management could be provided to the patient. Review of agency contracts revealed no documented evidence that the agency had a contract for hospice inpatient care for pain control and symptom management. During an interview on 07/09/2024, the Director of Nursing confirmed that the agency did not have a contract for hospice inpatient care for pain control and symptom management. Upon reviewing the contracts, the documentation lacked evidence of a contract for hospice inpatient care for pain control and symptom management.”

“It is required that hospice inpatient care for respite purposes is provided by one of the following: a Medicare-certified hospital or a skilled-nursing facility that also meets the standards specified in §418.110(b) (requiring 24-hour nursing care); and §418.110(f) (regarding home-like patient areas), a Medicare or Medicaid certified nursing facility that meets §418.110(f) (regarding home-like patient areas), or a Medicare-certified hospice that meets the conditions of participation for providing inpatient care directly as specified in §418.110. This standard was not met as evidenced by document review and interview. The hospice did not ensure inpatient care for respite purposes could be provided to the patient. Review of agency contracts revealed no documented evidence that the agency had a contract for hospice inpatient care for respite purposes. During an interview on 07/09/2024, the Director of Nursing confirmed that the agency did not have a contract for hospice inpatient care for respite purposes. Upon reviewing the contracts, the documentation lacked evidence of a contract for hospice inpatient care for respite purposes.”

“It is required that criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by personnel record review and interview. In 7 of 12 (58%) personnel records reviewed, the agency did not ensure that the criminal background checks were obtained within three months of the date of employment. Personnel Record 2: Director of Nursing’s date of hire 04/15/2022. Review of the personnel record revealed no documented evidence that a criminal background check was completed within three months of the date of employment. Personnel Record 5: Registered Nurse date of hire 03/25/2024. Review of the personnel record revealed no documented evidence that a criminal background check was completed within three months of the date of employment. Personnel Record 7: Chaplain/Bereavement Coordinator date of hire 04/16/2022. Review of the personnel record revealed no documented evidence that a criminal background check was completed within three months of the date of employment. Personnel Record 8: Hospice Aide date of hire 10/01/2022. Review of the personnel record revealed no documented evidence that a criminal background check was completed within three months of the date of employment. Personnel Record 9: Hospice Aide date of hire 04/01/2024. Review of the personnel record revealed no documented evidence that a criminal background check was completed within three months of the date of employment. Personnel Record 11: Licensed Vocational Nurse date of hire 12/18/2023. Review of the personnel record revealed no documented evidence that a criminal background check was completed within three months of the date of employment. Personnel Record 12: Volunteer Coordinator date of hire 11/22/2021. Review of the personnel record revealed no documented evidence that a criminal background check was completed within three months of the date of employment. During a joint review of personnel records and interview on 07/12/2024, the Director of Nursing confirmed that the records did not include documentation of a criminal background check within three months of the date of employment.”