Ec Lilly Palliative Care & Hospice Agency, Inc.

“Based on observation, interview, and record review, the Hospice Agency failed to provide written notice of patient’s rights and responsibilities during an initial visit for one out of five sampled patients (Patient 2).This failure had the potential for Patient 2 and/or Patient 2’s representative to not be aware of the patient’s rights and responsibilities. A review of Patient 2’s clinical records indicated Patient 2 had a start of care date with the Hospice Agency on 2/27/25 and had diagnoses that included Amyotrophic Lateral Sclerosis (ALS- a progressive disease that affects nerve cells controlling voluntary muscle movement).During a concurrent observation and interview on 6/16/25, during a home visit at 1:20 p.m., with Hospice Aide (HA), the Chief Executive Officer (CEO) was observed delivering an admission packet to Patient 2’s house. HA confirmed the observation.During a concurrent interview and record review on 6/16/25, during a home visit at 1:34 p.m., with Patient 2’s husband, Patient 2’s admission packet was reviewed. The admission packet included a written notice of patient’s rights and responsibilities. Patient 2’s husband confirmed that they only received the admission packet which included a written notice of patient’s rights and responsibilities today when the CEO delivered it.During an interview on 6/17/25 at 11:50 a.m., with the CEO, the CEO confirmed Patient 2’s admission packet which included a written notice of patient’s rights and responsibilities was only delivered yesterday.During an interview on 6/17/25 at 11:50 a.m., with the Alternate Director of Patient Care Services (Alt. DPCS), the Alt. DPCS stated that written notice of patient’s rights and responsibilities are included in the admission packet which should be provided to the patient and/or patient representative during admission to the hospice agency. A review of the facility’s policy and procedure (P&P) titled, “PATIENT PRIVACY RIGHTS”, revised 4/2020, indicated, “The patient will be provided with information about his/her privacy rights in the organization’s Notice of Privacy Practices, which will be given to the patient during the admission visit...””

“Based on observation, interview, and record review, the Hospice Agency failed to provide a written plan of care which includes information about the scope of services that the hospice will provide for one out of five sampled patients (Patient 2).This failure had the potential for Patient 2 and/or Patient 2’s caregiver to not be aware of the scope of services that the hospice will provide to Patient 2. A review of Patient 2’s clinical records indicated Patient 2 had a start of care date with the Hospice Agency on 2/27/25 and had diagnoses that included Amyotrophic Lateral Sclerosis (ALS- a progressive disease that affects nerve cells controlling voluntary muscle movement).During a concurrent observation and interview on 6/16/25, during a home visit at 1:20 p.m., with Hospice Aide (HA), the Chief Executive Officer (CEO) was observed delivering the admission packet to Patient 2’s house. HA confirmed the observation.During a concurrent interview and record review on 6/16/25, during a home visit at 1:34 p.m., with Patient 2’s husband, Patient 2’s admission packet was reviewed. The admission packet included a written plan of care which includes information about the scope of services that the hospice will provide. Patient 2’s husband confirmed that they only received the admission packet which included a written plan of care which included information about the scope of services that the hospice will provide, today, when the CEO delivered it.During an interview on 6/17/25 at 11:50 a.m., with the CEO, the CEO confirmed Patient 2’s admission packet which included a written plan of care that included information about the scope of services that the hospice will provide was only delivered yesterday.During an interview on 6/17/25 at 11:50 a.m., with the Alternate Director of Patient Care Services (Alt. DPCS), the Alt. DPCS stated that the plan of care which includes information about the scope of services that the hospice will provide should be provided to the patient and/or patient representative.A review of the facility’s policy and procedure (P&P) titled, “THE PLAN OF CARE”, revised 4/2020, indicated, “To ensure that an individualized plan of care is completed that complies with accepted standard of care and regulatory issues...4. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver ‘s needs.””

“Based on interview and record review, the agency failed to ensure the comprehensive assessment was completed by the hospice interdisciplinary group (IDT) for one of five sampled patients (Patient 1).This failure had the potential for Patient 1 to receive inaccurate care. A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the Hospice Agency on 5/12/25 and had diagnoses that included disease with cerebral vascular involvement (problems with blood flow to the brain). During a review of Patient 1’s facility documents titled, “IDT Plan of Care & Review of Comprehensive Assessment”, dated 5/20/25 and 6/3/25, revealed the comprehensive assessments were not signed by the interdisciplinary team. During a concurrent interview and record review on 6/17/25 at 11:25 a.m. with the QARN (Quality Assurance RN), Patient 1’s clinical records were reviewed. The QARN confirmed the IDT Plan of Care & Review of Comprehensive Assessment forms, dated 5/20/25 and 6/3/25, were not signed by the interdisciplinary team but should have been per facility policy. The QARN further stated without signatures on the forms, there was no proof that the interdisciplinary team had reviewed and approved the care plan and assessment. During a review of the agency’s policy and procedure (P&P) titled, “Interdisciplinary Group Membership and Responsibilities,” revised April 2020 indicated, “The interdisciplinary group will collaborate with the patient’s attending physician to develop an individualized written plan of care…interdisciplinary group membership includes at a minimum: A. Physician B. Registered Nurse C. Social Worker D. Pastoral or other counselor (s)…interdisciplinary group responsibilities include…participation in the periodic review and updating of the plan of care for each patient receiving hospice services…””

“Based on interview and record review, the Hospice Agency failed to ensure that the care and services are provided in accordance with the plan of care for one out of five sampled patients (Patient 2) when Patient 2’s Skilled Nursing (SN) frequency of visit order was not followed.This failure had the potential for Patient 2 to not receive required skilled nursing services negatively affecting Patient 2’s comfort and well-being. A review of Patient 2’s clinical records indicated Patient 2 had a start of care date with the Hospice Agency on 2/27/25 and had diagnoses that included Amyotrophic Lateral Sclerosis (ALS- a progressive disease that affects nerve cells controlling voluntary muscle movement).A review of Patient 2’s physician’s order dated 2/27/25 indicated, “Skilled Nursing visit frequency: 1 x week (once a week) and as needed for pain, symptom management and crisis intervention.”A review Patient 2’s visit calendar indicated Patient 2 was not visited by a skilled nurse on the week of 4/27/25 to 5/3/25 and the week of 5/11/25 to 5/17/25.During a concurrent interview and record review on 6/17/25 at 11:50 a.m., with the Alternate Director of Patient Care Services (Alt. DPCS), Patient 2’s clinical records were reviewed. The Alt. DPCS confirmed that Patient 2’s skilled nursing frequency of visit order was not followed and stated the physician’s order should be followed.A review of the facility’s policy and procedure (P&P) titled, “THE PLAN OF CARE”, revised 4/2020, indicated, “To ensure that an individualized plan of care is completed that complies with accepted standard of care and regulatory issues...4. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs.””

“Based on interview and record review, the Hospice Agency failed to ensure Hospice Aid care plans were developed and prepared by a registered nurse (RN) for three out of five sampled patients (Patient 1, Patient 2, and Patient 3) when: 1. Patient 1’s 5/13/25 Hospice Aide care plan and Patient 2’s 2/27/25 Hospice Aide care plan was not signed by an RN;2. Patient 2 had no developed Hospice Aid care plan for 5/28/25 to 8/25/25 re-certification period; and,3. Patient 3’s 5/25/25 Hospice Aide Care Plan was not complete.This failure had the potential for Patient 1, 2, and 3 to receive unsafe and innacurate patient care from a hospice aid. 3. During a concurrent interview and record review on 6/17/25 at 10:05 a.m. with the Alternate Director of Patient Care Services (DPCS) and the Quality Assurance Registered Nurse (QARN), Patient 3’s “Hospice Aide Care Plan,” dated 5/25/25 was reviewed. The Hospice Aide Care Plan did not contain the frequency of the of Hospice Aide tasks. The “Hospice Aide Care Plan” indicated “Assignments: Specify frequencies of tasks and days of the week to complete the task.” The Alternate DPCS and QARN confirmed Patient 3’s Hospice Aide Care Plan was incomplete and did not contain the frequency of the Hospice Aide tasks. During a review of the agency’s policy and procedure (P&P) titled, “Hospice Aide Supervisory Visits,” revised April 2020 indicated, “The Case Manage will be responsible for: A. Providing written instructions to ensure compliance with the plan of care…” 1b. A review of Patient 2’s clinical records indicated Patient 2 had a start of care date with the Hospice Agency on 2/27/25 and had diagnoses that included Amyotrophic Lateral Sclerosis (ALS- a progressive disease that affects nerve cells controlling voluntary muscle movement).A review of Patient 2’s physician’s order dated 2/27/25 indicated, “Hospice Aid Visit frequency: 2 x week (twice a week) for personal care and assistance.”A review Patient 2’s Hospice Aid care plan dated 2/27/25 indicated the care plan was not signed by an RN.During a concurrent interview and record review on 6/17/25 at 11:50 a.m., with the Alternate Director of Patient Care Services (Alt. DPCS), Patient 2’s clinical records were reviewed. The Alt. DPCS confirmed that Patient 2’s Hospice Aid care plan dated 2/27/25 was not signed by an RN. The Alt. DPCS stated that Hospice Aid care plans should be made and signed by an RN.2. A review of Patient 2’s physician’s order dated 5/13/23 indicated, “CHHA [Hospice Aid] Visit frequency: 2 visits per week for ADL [Activities of Daily Living- refer to the fundamental self-care tasks that people perform daily to maintain their well-being and independence] assistance.”A review Patient 2’s clinical records did not indicate a developed Hospice Aid care plan of Patient 2 for 5/28/25 to 8/25/25 re-certification period.During a concurrent interview and record review on 6/17/25 at 11:50 a.m., with the Alt. DPCS, Patient 2’s clinical records were reviewed. The Alt. DPCS confirmed that Patient 2 had no developed Hospice Aid care plan for 5/28/25 to 8/25/25 re-certification period. The Alt. DPCS stated that Patient 2 should have a developed Hospice Aid care plan by an RN is Patient 2 is being visited by a Hospice Aid so the aid would know what to do.A review of the facility’s policy and procedure (P&P) titled, “HOSPICE AIDE SERVICES”, revised 4/2020, indicated, “...Services provided by an aide could include bathing, shampoo, rang of motion activities, dry dressing changes, assisting the patient to the bathroom, use of commode or bed pan, assisting with meal preparation, feeding the patient, light housekeeping and/or linen changes. These activities in accordance with the plan of care and physician’s (or other authorized independent practitioner’s) orders will be assigned and supervised by a hospice registered nurse....” A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the Hospice Agency on 5/12/25 and had diagnoses that included disease with cerebral vascular involvement (problems with blood flow to the brain). During a review of Patient 1’s facility document titled, “Hospice Aide Care Plan”, dated 5/13/25, revealed the care plan was not signed by a registered nurse. During a concurrent interview and record review on 6/17/25 at 11:25 a.m. with the QARN (Quality Assurance RN), Patient 1’s clinical records were reviewed. The QARN confirmed the Hospice Aide Care Plan was not signed by the registered nurse but should have been per facility policy. The QARN further stated she could not confirm the care plan was completed by a registered nurse if there was not a signature. During a review of the agency’s policy and procedure (P&P) titled, “Hospice Aide Supervisory Visits,” revised April 2020 indicated, “The Case Manage will be responsible for: A. Providing written instructions to ensure compliance with the plan of care…”During a review of the agency’s P&P titled, “Hospice Aide Services,” revised April 2020 indicated, “Hospice aide services will include personal care services provided by trained hospice aides…These activities in accordance with the plan of care…will be assigned and supervised by a hospice registered nurse.””

“Based on interview and record review, the Hospice Agency failed to ensure Hospice Aid provided services in accordance with the ordered frequency of visit from 12/6/23 to 5/3/24 for one out of five sampled patients (Patient 5).This failure had the potential for Patient 2 to not receive necessary patient care to maintain comfort and well-being. A review of Patient 5’s clinical records indicated Patient 5 had a start of care date with the Hospice Agency on 9/7/25 and had diagnoses that included congestive heart failure (CHF- occurs when the heart can’t pump enough blood to meet the body’s needs).A review of Patient 5’s physician’s order dated 11/28/23 indicated, “Re-certify patient on 12/6/23...CHHA [Hospice Aid] Visit frequency: 2 visits per week for ADL [Activities of Daily Living- refer to the fundamental self-care tasks that people perform daily to maintain their well-being and independence] assistance.”A review of Patient 5’s physician’s order dated 2/21/24 indicated, “Re-certify patient on 03/05/24...CHHA [Hospice Aid] Visit frequency: 1 visit per week for ADL assistance.”A review Patient 5’s calendar of visits indicated Patient 5 had no Hospice Aid visit from 12/6/23 to 5/3/24.During a concurrent interview and record review on 6/17/25 at 11:50 a.m., with the Alternate Director of Patient Care Services (Alt. DPCS), Patient 5’s clinical records were reviewed. The Alt. DPCS confirmed that Patient 5’s ordered frequency of visit from Hospice Aid from 12/6/23 to 5/3/24 was not followed. The Alt. DPCS stated that ordered Hospice Aid visit frequency should be followed so the Hospice Aid can provide the ordered services for Patient 5.A review of the facility’s policy and procedure (P&P) titled, “HOSPICE AIDE SERVICES”, revised 4/2020, indicated, “...Services provided by an aide could include bathing, shampoo, rang of motion activities, dry dressing changes, assisting the patient to the bathroom, use of commode or bed pan, assisting with meal preparation, feeding the patient, light housekeeping and/or linen changes. These activities in accordance with the plan of care and physician’s (or other authorized independent practitioner’s) orders will be assigned and supervised by a hospice registered nurse....””

“Based on interview and record review, the agency failed to have signed copies of the notice of patient rights for one of five sampled patients (Patient 3). This failure resulted in the patient or their representative unaware of the patient rights and responsibilities. During a review of Patient 3’s clinical record revealed no documentation of a signed copy of the notice of patient rights. During an interview on 6/17/25 at 10:05 a.m. with the Alternate Director of Patient Care Services (DPCS) and the Quality Assurance Registered Nurse (QARN) they confirmed they were unable to produce signed copies of Patient 3’s notice of patient rights.During a review of the agency’s policy and procedure (P&P) titled, “Patient Privacy Rights,” revised April 2020 indicated, “The patient will be provided with information about his/her privacy rights in the organization’s Notice of Privacy Practices, which will be given to the patient during the admission visit.””

“Based on interview and record review, the Hospice Agency failed to ensure clinical records were completed in a timely manner for one out of five sampled patients (Patient 2).This failure had the potential for Patient 2 to not have an updated and complete clinical record which were necessary to deliver appropriate care and services. A review of Patient 2’s clinical records indicated Patient 2 had a start of care date with the Hospice Agency on 2/27/25 and had diagnoses that included Amyotrophic Lateral Sclerosis (ALS- a progressive disease that affects nerve cells controlling voluntary muscle movement).A review of Patient 2’s physician’s order dated 2/27/25 indicated, “Skilled Nursing visit frequency: 1 x week (once a week) and as needed for pain, symptom management and crisis intervention.”A review Patient 2’s clinical records indicated Patient 2’s nursing clinical note dated 4/13/25 was still in progress and a nursing clinical note dated 5/20/25 was still not started. During a concurrent interview and record review on 6/17/25 at 11:50 a.m., with the Alternate Director of Patient Care Services (Alt. DPCS), Patient 2’s clinical records were reviewed. The Alt. DPCS confirmed that Patient 2’s nursing clinical notes dated 4/13/25 and 5/20/25 were both not completed in a timely manner. The Alt. DPCS stated the notes should have been completed.A review of the facility’s job description summary for registered nurse, revised 4/2020, indicated, “ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES...Communication...1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.””

“Based on interview and record review, the Hospice Agency failed to provide the agency’s written policies and procedures (P&P) on the management and disposal of controlled drugs (medications with high potential for abuse or addiction) for one out of five sampled patients (Patient 2). This failure had the potential for Patient 2 and/or Patient 2’s caregiver to not be aware of proper management and disposal of controlled drugs. A review of Patient 2’s clinical records indicated Patient 2 had a start of care date with the Hospice Agency on 2/27/25 and had diagnoses that included Amyotrophic Lateral Sclerosis (ALS- a progressive disease that affects nerve cells controlling voluntary muscle movement).A review of Patient 2’s physician’s order dated 2/27/25 indicated, “Tramadol [a controlled medication used to treat moderate to severe pain] 50 mg [milligrams- unit of measurement] Oral Tablet, Administer 1 tablet, orally [by mouth], 1-2 tablets a day as needed for moderate to severe pain.”During a concurrent interview and record review on 6/16/25, during a home visit at 1:34 p.m., with Patient 2’s husband, Patient 2’s Hospice binder was reviewed. Patient 2’s husband confirmed that Patient 2’s Hospice binder did not include written P&P on the management and disposal of controlled drugs.During an interview on 6/17/25 at 11:50 a.m., with the Alternate Director of Patient Care Services (Alt. DPCS), the Alt. DPCS stated that the regulation should be followed and the agency’s written P&P on the management and disposal of controlled drugs should have been provided to Patient 2 and/or Patient 2’s representative.A review of the facility’s admission packet, undated, indicated that “Drug Disposal Policy” is listed as one of the types of information to be explained/provided to the patient and/or patient’s representative.”

“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 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 CONTINUING CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by review of clinical records, and interviews with the Director of Patient Care Services which revealed continued issues with the lack of documented evidence regarding the development and implementation of patients’ interdisciplinary care plans in the following areas: Failed to ensure the individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following drugs and treatments necessary to meet the needs of the patient {HCPC.21.I/L549/418.56(c)(4)}; Failed to ensure that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, include the following medical supplies and appliances necessary to meet the needs of the patient {{HCPC.21.I/L549/418.56(c)(5)}; and Failed to ensure Interdisciplinary group (IDG) reviewed, revised, and documented the individualized care plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days {HCPC.22.I/L552/418.56(d)}. HCPC.22.I/L552 is a continuing required action, which was cited on the renewal visit of 10/09/2024 for 4 of 4 (100%) clinical records with incomplete documentation of interdisciplinary group (IDG) review of the plan of care no less frequently than every 15 calendar days. HCPC.22.I/L552 was recited on the 11/15/2024 visit with 4 of 4 (100%) clinical records with incomplete documentation of IDG review of the plan of care at lease every 15 days and was cited during this visit in 4 of 4 (100%) clinical records with records with incomplete documentation of IDG review of the plan of care no less frequently than every 15 calendar days. 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 services must by consistent with current professional standards of practice, licensed professionals actively participate in the coordination of aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments; developing and evaluating the plan of care; and contributing to patient and family counseling and education. t 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. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record review and interviews with the Medical Director and Director of Patient Care Services which revealed issues with the agency’s ability to provide core services in the following areas: Failed to ensure that the hospice Medical Director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness {HCDT.5.I/L590/418.64(a)}; and Failed to ensure that when the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director {HCDT.5.I/L590/418.64(a)(3)}. 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 documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; 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 and interview. In 1 of 4 (25%) clinical records reviewed, it was revealed that the organization did not ensure that a drug profile that contained the patient’s current OTC drugs was documented with all actual or potential drug interactions identified. CLINICAL RECORD 1: The patient was admitted to hospice services on 08/10/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, urinary incontinence, and Type 2 Diabetes Mellitus with diabetic kidney complications. Benefit Period 8 was effective 12/02/2024 to 01/30/2025. During a concurrent review of the clinical record and interview with the DPCS/RN (Director of Patient Care Services/Registered Nurse) on 01/7/2025, the DPCS/RN confirmed that the MSW (Medical Social Worker) clinical note dated 12/23/2024 documented that the patient’s back pain was reported by the patient to be palliated by using Tylenol and Motrin. The DPCS/RN confirmed that the patient’s drug profile did not include Tylenol or Motrin and that neither medication had been evaluated for actual or potential drug interactions as required and stated, “She never told me she was taking those medications. I did not know.””

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed, it was revealed that the organization did not ensure that each patient’s individualized written plan of care included all drugs necessary to meet the needs of each patient. CLINICAL RECORD 1: The patient was admitted to hospice services on 08/10/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, urinary incontinence, and Type 2 Diabetes Mellitus with diabetic kidney complications. Benefit Period 8 was effective 12/02/2024 to 01/30/2025. On 12/23/2024 the MSW (Medical Social Worker) documented that that the patient’s back pain was reported by the patient to be palliated by using Tylenol and Motrin. The DPCS/RN (Director of Patient Care Services/Registered Nurse) confirmed during a concurrent record review and interview, on 01/7/2025, that the patient’s medication profile on the plan of care did not include Tylenol or Motrin and stated, “She never told me she was taking those medications. I did not know to include them on her medication list.””

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed, it was revealed that the organization did not ensure that each patient’s individualized plan of care included all medical supplies and appliances necessary to meet the specific needs of the patient. CLINICAL RECORD 4: The patient was readmitted to hospice services on 05/17/2024 with primary terminal and pertinent secondary diagnoses that included age-related osteoarthritis with current pathological fracture, delayed healing; acute diastolic (congestive) heart failure, history of falls, lumbosacral plexus disorders, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit period 7 was effective 11/13/2024 to 01/11/2025. The clinical record was reviewed with the DPCS/RN (Director of Patient Care Services/Registered Nurse) on 01/07/2025, who confirmed that various clinical notes (by all disciplines) documented that the patient wore a back brace to palliate her chronic back pain. The DPCS confirmed that the patient’s medical supply list on the plan of care did not include the back brace and stated, “We did not supply the back brace. I thought we only had to put supplies that the hospice provided on the plan of care. I will add it.””

“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, interview and observation. In 4 of 4 (100%) clinical records reviewed, it was revealed that the organization did not ensure that the Interdisciplinary Group (IDG) in its entirety reviewed, revised, and documented the individualized care plan at least every 15 calendar days. CLINICAL RECORD 1: The patient was admitted to hospice services on 08/10/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, urinary incontinence, and Type 2 Diabetes Mellitus with diabetic kidney complications. Benefit Period 8 was effective 12/02/2024 to 01/30/2025. During a concurrent review of the clinical record and interview with the DPCS/RN (Director of Patient Care Services/Registered Nurse) on 01/07/2025, it was revealed that the hospice Medical Director did not attend the IDG meeting to review the patient’s plan of care on 12/24/2024. An observation of the IDG meeting on 01/07/2025 noted that it was attended by phone by the Chaplain, and in person by the MSW (Medical Social Worker), Aide, and DPCS/RN, however, the Medical Director arrived approximately 45 minutes after the conclusion of the meeting. Thus, two IDG meetings were conducted without a physician in attendance and the record lacked evidence that the IDG, in its entirety, reviewed and revised the patient’s care plan no less frequently than every 15 calendar days. CLINICAL RECORD 2: The patient was admitted to hospice services on 09/07/2023 with primary terminal and pertinent diagnoses that included acute on chronic diastolic (congestive) heart failure, hypertension, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit Period 7 was effective 10/31/2024 to 12/29/2024 and Benefit Period 8 was effective 12/30/2024 to 02/27/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was revealed that the hospice Medical Director did not attend the IDG meeting to review the patient’s plan of care on 12/24/2024. An observation of the IDG meeting on 01/07/2025 noted that it was attended by phone by the Chaplain, and in person by the MSW, Aide, and DPCS/RN, however, the Medical Director arrived approximately 45 minutes after the conclusion of the meeting. Thus, two IDG meetings were conducted without a physician in attendance and the record lacked evidence that the IDG, in its entirety, reviewed and revised the patient’s care plan no less frequently than every 15 calendar days. CLINICAL RECORD 3: The patient was admitted to hospice services on 07/13/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, mixed incontinence, muscle weakness, repeated falls, and shortness of breath. Benefit Period 8 was effective 11/04/2024 to 01/02/2025 and Benefit Period 9 was effective 01/03/2025 to 03/03/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was revealed that the hospice Medical Director did not attend the IDG meeting to review the patient’s plan of care on 12/24/2024. An observation of the IDG meeting on 01/07/2025 noted that it was attended by phone by the Chaplain, and in person by the MSW, Aide, and DPCS/RN, however, the Medical Director arrived approximately 45 minutes after the conclusion of the meeting. Thus, two IDG meetings were conducted without a physician in attendance and the record lacked evidence that the IDG, in its entirety, reviewed and revised the patient’s care plan no less frequently than every 15 calendar days. CLINICAL RECORD 4: The patient was readmitted to hospice services on 05/17/2024 in the 4th Benefit Period with primary terminal and pertinent secondary diagnoses that included Age-related OA with current pathological fracture, delayed healing; acute diastolic (congestive) heart failure, history of falls, lumbosacral plexus disorders, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit period 7 was effective 11/13/2024 to 01/11/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was revealed that the hospice Medical Director did not attend the IDG meeting to review the patient’s plan of care on 12/24/2024. An observation of the IDG meeting on 01/07/2025 noted that it was attended by phone by the Chaplain, and in person by the MSW, Aide, and DPCS/RN, however, the Medical Director arrived approximately 45 minutes after the conclusion of the meeting. Thus, two IDG meetings were conducted without a physician in attendance and the record lacked evidence that the IDG, in its entirety, reviewed and revised the patient’s care plan no less frequently than every 15 calendar days.”

“It is required that the Hospice Medical Director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. The hospice must designate a physician to serve as Medical Director. The Medical Director must be a Doctor of Medicine or osteopathy who is an employee or is under contract with the hospice. When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. This standard was not met as evidenced by interview. The organization did not ensure that the hospice designated a backup physician to assume the same responsibilities and obligations as the Medical Director in cases of the absence of the Hospice Medical Director. During an interview with the Administrator on 01/06/2025, the Administrator stated that the organization had attempted to contract with a backup hospice physician but, “since the last site visit but he’s on vacation and hasn’t signed the contract.” The Administrator confirmed that the agency did not have a backup hospice physician contracted or employed at the time of this visit. The organization failed to ensure that the hospice designated a backup physician to assume the same responsibilities and obligations as the medical director in cases of the absence of the hospice medical director. During an interview with the Administrator on 01/06/2025, the Administrator stated that the organization had attempted to contract with a backup hospice physician “since the last site visit but he’s on vacation and hasn’t signed the contract”. The Administrator also stated that a backup physician had not been screened, oriented, or onboarded as required by organizational policies.”

“It is required that the hospice Medical Director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, it was revealed that the organization did not ensure that the hospice Medical Director, physician employee, or contracted physician assumed responsibility for the palliation and management of each patient’s terminal illness and conditions related to the terminal illness by performing face-to-face examinations required for the third and later hospice benefit periods. CLINICAL RECORD 1: The patient was admitted to hospice services on 08/10/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, urinary incontinence, and Type 2 Diabetes Mellitus with diabetic kidney complications. Benefit Period 8 was effective 12/02/2024-01/30/2025. During a concurrent review of the clinical record and interview with the DPCS/RN (Director of Patient Care Services/Registered Nurse) on 01/7/2025, it was confirmed that the patient’s clinical record contained no documented evidence of face-to-face visits or clinical examinations performed by an authorized licensed practitioner for the third or later hospice benefit periods. CLINICAL RECORD 2: The patient was admitted to hospice services on 09/07/2023 with primary terminal and pertinent secondary diagnoses that included acute on chronic diastolic (congestive) heart failure, hypertension, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit Period 7 was effective 10/31/2024-12/29/2024 and Benefit Period 8 was effective 12/30/2024-02/27/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was confirmed that the patient’s clinical record contained no documented evidence of face-to-face visits or clinical examinations performed by an authorized licensed practitioner for the third or later hospice benefit period. CLINICAL RECORD 3: The patient was admitted to hospice services on 07/13/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, mixed incontinence, muscle weakness, repeated falls, and shortness of breath. Benefit Period 8 was effective 11/04/2024-01/02/2025 and Benefit Period 9 was effective 01/03/2025-03/03/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was that confirmed that the patient’s clinical record contained no documented evidence of face-to-face visits or clinical examinations performed by an authorized licensed practitioner for the third or later hospice benefit period. CLINICAL RECORD 4: The patient was readmitted to hospice services on 05/17/2024 in the 4th Benefit Period with primary terminal and pertinent secondary diagnoses that included Age-related OA with current pathological fracture, delayed healing; acute diastolic (congestive) heart failure, history of falls, lumbosacral plexus disorders, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit period 7 was effective 11/13/2024-01/11/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was confirmed that the patient’s clinical record contained no documented evidence of face-to-face visits or clinical examinations performed by an authorized licensed practitioner for the third or later hospice benefit period. The Hospice Medical Director was interviewed on 01/07/2024 and reported that he had never performed a face-to-face visit for any of the benefit periods and stated, “I haven’t seen the patients, but I should see the patients. We will start doing that.””

“It is required that volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, that included volunteer services ordered by the Interdisciplinary Group (IDG), it was revealed that the organization did not ensure that volunteer services were specified and performed according to the plan of care. CLINICAL RECORD 2: The patient was admitted to hospice services on 09/07/2023. Benefit Period 7 was effective 10/31/2024 to 12/29/2024 and Benefit Period 8 was effective 12/30/2024 to 02/27/2025. During a concurrent review of the clinical record and interview with the DPCS/RN (Director of Patient Care Services/Registered Nurse) on 01/7/2025, the DPCS/RN stated that the Recertification Plans of Care for Benefit Periods 7 and 8 included orders for monthly volunteer visits. The DPCS/RN also confirmed that the last documented Volunteer Plan of Care ended on 10/30/2024, which coincided with the end of Benefit Period 6. “The patient wants a volunteer, but our volunteer is on leave and was absent all of November and December. We are recruiting.” CLINICAL RECORD 3: The patient was admitted to hospice services on 07/13/2023. Benefit Period 8 was effective 11/04/2024-01/02/2025 and Benefit Period 9 was effective 01/03/2025-03/03/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, the DPCS/RN stated that the Recertification Plans of Care for Benefit Periods 8 and 9 included orders for monthly volunteer visits. The DPCS/RN also confirmed that the last documented Volunteer Plan of Care ended on 11/03/2024, which coincided with the end of Benefit Period 7. “The patient wants a volunteer, but our volunteer is on leave and was absent all of November and December. We are recruiting.””

“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. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, it was revealed that the organization did not ensure that recertification for the hospice care benefit was informed by the Medical Director’s review of each patient’s clinical information which included a face-to-face clinical examination of patients in the third and subsequent benefit periods. Per the Code of Federal Regulations Part 418 (Hospice Care) Subpart B (Eligibility, Election and Duration of Benefits) section 418.22 Certification of terminal illness required in part, “(4) Face-to-face encounter (i) As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.” CLINICAL RECORD 1: The patient was admitted to hospice services on 08/10/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, urinary incontinence, and Type 2 Diabetes Mellitus with diabetic kidney complications. Benefit Period 8 was effective 12/02/2024 to 01/30/2025. During a concurrent review of the clinical record and interview with the DPCS/RN (Director of Patient Care Services/Registered Nurse) on 01/7/2025, it was confirmed that the patient’s clinical record contained no documented evidence of face-to-face visits or clinical examinations performed by an authorized licensed practitioner for the third or later hospice benefit periods. CLINICAL RECORD 2: The patient was admitted to hospice services on 09/07/2023 with primary terminal and pertinent diagnoses that included acute on chronic diastolic (congestive) heart failure, hypertension, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit Period 7 was effective 10/31/2024-12/29/2024 and Benefit Period 8 was effective 12/30/2024 to 02/27/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was confirmed that the patient’s clinical record contained no documented evidence of face-to-face visits or clinical examinations performed by an authorized licensed practitioner for the third or later hospice benefit period. CLINICAL RECORD 3: The patient was admitted to hospice services on 07/13/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, mixed incontinence, muscle weakness, repeated falls, and shortness of breath. Benefit Period 8 was effective 11/04/2024-01/02/2025 and Benefit Period 9 was effective 01/03/2025-03/03/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was confirmed that the patient’s clinical record contained no documented evidence of face-to-face visits or clinical examinations performed by an authorized licensed practitioner for the third or later hospice benefit period. CLINICAL RECORD 4: The patient was readmitted to hospice services on 05/17/2024 in the 4th Benefit Period with primary terminal and pertinent secondary diagnoses that included Age-related OA with current pathological fracture, delayed healing; acute diastolic (congestive) heart failure, history of falls, lumbosacral plexus disorders, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit period 7 was effective 11/13/2024 to 01/11/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/7/2025, it was confirmed that the patient’s clinical record contained no documented evidence of face-to-face visits or clinical examinations performed by an authorized licensed practitioner for the third or later hospice benefit period. During an interview on 01/07/2024 the Hospice Medical Director stated that he had never performed face-to-face visits before the patient’s third benefit period, or any benefit period after, for these patients. Therefore, the Medical Director was unable to gather clinical findings to determine continued eligibility for an informed signed recertification period.”

“It is required that each patient’s record includes, at a minimum: Physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, it was revealed that the organization did not ensure that each patient record included a completed and signed physician recertification of terminal illness as required. CLINICAL RECORD 1: The patient was admitted to hospice services on 08/10/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, urinary incontinence, and Type 2 Diabetes Mellitus with diabetic kidney complications. Benefit Period 8 was effective 12/02/2024 to 01/30/2025. During a concurrent review of the clinical record and interview with the DPCS/RN (Director of Patient Care Services/Registered Nurse) on 01/6/2025, it was confirmed that the clinical record did not include a written and signed recertification of terminal illness for Benefit Period 8. The Recertification Plan of Care in the patient record dated 11/26/2024 was blank on the page titled Certification of Terminal Illness Physician Narrative Statement and contained no physician signature. On 01/07/2025, Medical Director signed a Word document with typed clinical findings that DPCS stated was a Certification of Terminal Illness for Benefit Period 8 effective 12/02/2024 to 01/30/2025. CLINICAL RECORD 2: The patient was admitted to hospice services on 09/07/2023 with primary terminal and pertinent diagnoses that included acute on chronic diastolic (congestive) heart failure, hypertension, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit Period 7 was effective 10/31/2024 to 12/29/2024 and Benefit Period 8 was effective 12/30/2024 to 02/27/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/6/2025, it was confirmed that the clinical record did not include a written and signed recertification of terminal illness for Benefit Periods 7 or 8. The Recertification Plan of Care in the patient record dated 10/17/2024 was blank on the page titled Certification of Terminal Illness Physician Narrative Statement and contained no physician signature. The Recertification Plan of Care in the patient record dated 12/16/2024 was also blank on the page titled Certification of Terminal Illness Physician Narrative Statement and contained no physician signature. On 1/7/2025, the Medical Director signed Word documents with typed clinical findings that the DPCS stated was a Certification of Terminal Illness for Benefit Period 7 effective 10/31/2024 to 12/29/2024 and Benefit Period 8 effective 12/30/2024 to 02/27/2025. CLINICAL RECORD 3: The patient was admitted to hospice services on 07/13/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, mixed incontinence, muscle weakness, repeated falls, and shortness of breath. Benefit Period 8 was effective 11/04/2024-01/02/2025 and Benefit Period 9 was effective 01/03/2025 to 03/03/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/6/2025, it was confirmed that the clinical record did not include a written and signed recertification of terminal illness for Benefit Periods 8 or 9. The Recertification Plan of Care in the patient record dated 10/21/2024 was blank on the page titled Certification of Terminal Illness Physician Narrative Statement and contained no physician signature. The Recertification Plan of Care in the patient record dated 12/20/2024 was also blank on the page titled Certification of Terminal Illness Physician Narrative Statement and contained no physician signature. On 1/7/2025, the Medical Director signed Word documents with the header/title “CTI” that the DPCS stated was a Certification of Terminal Illness for Benefit Period 8 effective 11/04/2024 to 01/02/2025 and Benefit Period 9 effective 01/03/2025 to 03/03/2025. CLINICAL RECORD 4: The patient was readmitted to hospice services on 05/17/2024 in the 4th Benefit Period with primary terminal and pertinent secondary diagnoses that included Age-related OA with current pathological fracture, delayed healing; acute diastolic (congestive) heart failure, history of falls, lumbosacral plexus disorders, and Type 2 Diabetes Mellitus with diabetic neuropathy. Benefit period 7 was effective 11/13/2024 to 01/11/2025. During a concurrent review of the clinical record and interview with the DPCS/RN on 01/6/2025, it was confirmed that the clinical record did not include a written and signed recertification of terminal illness for Benefit Period 7. The Recertification Plan of Care in the patient record dated 11/07/2024 was blank on the page titled Certification of Terminal Illness Physician Narrative Statement and contained no physician signature. On 1/7/2025, the Medical Director signed a Word document with the header/title “CTI” that the DPCS stated was a Certification of Terminal Illness for Benefit Period 7 effective 11/13/2024 to 01/11/2025.”

“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 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 4 of 4 (100%) clinical records reviewed, it was revealed that the organization did not ensure that the hospice Medical Director completed written and signed recertification within the required timeframes, no later than two (2) calendar days after the first day of each benefit period. CLINICAL RECORD 1: The patient was admitted to hospice services on 08/10/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, urinary incontinence, and Type 2 Diabetes Mellitus with diabetic kidney complications. On 1/7/2025, 36 days after the first day of Benefit Period 8 (effective 12/02/2024 to 01/30/2025), the Medical Director signed a Word document with typed clinical findings that DPCS (Director of Patient Care Services/Registered Nurse) stated was a Certification of Terminal Illness for Benefit Period 8. When the Medical Director was asked how the Word document was created and when he had composed the narrative, he was unable to articulate the process of how or when the document was composed but stated he came to the office to sign documents as requested. CLINICAL RECORD 2: The patient was admitted to hospice services on 09/07/2023 with primary terminal and pertinent diagnoses that included acute on chronic diastolic (congestive) heart failure, hypertension, and Type 2 Diabetes Mellitus with diabetic neuropathy. On 1/7/2025, 68 days after the first day of Benefit Period 7 (effective 10/31/2024 to 12/29/2024) and 7 days after the first day of Benefit Period 8 (effective 12/30/2024 to 02/27/2025), the Medical Director signed a Word document with typed clinical findings that DPCS stated was a Certification of Terminal Illness for Benefit Period 7 and Benefit Period 8. When the Medical Director was asked how the Word document was created and when he had composed the narrative, he was unable to articulate the process of how or when the document was composed but stated he came to the office to sign documents as requested. CLINICAL RECORD 3: The patient was admitted to hospice services on 07/13/2023 with primary terminal and pertinent secondary diagnoses that included Alzheimer’s Disease, mixed incontinence, muscle weakness, repeated falls, and shortness of breath. On 1/7/2025, 64 days after the first day of Benefit Period 8 (effective 11/04/2024 to 01/02/2025) and 4 days after the first day of Benefit Period 9 (effective 01/03/2025 to 03/03/2025), the Medical Director signed a Word document with typed clinical findings that DPCS stated was a Certification of Terminal Illness for Benefit Period 7 and Benefit Period 8. When the Medical Director was asked how the Word document was created and when he had composed the narrative, he was unable to articulate the process of how or when the document was composed but stated he came to the office to sign documents as requested. CLINICAL RECORD 4: The patient was readmitted to hospice services on 05/17/2024 in the 4th Benefit Period with primary terminal and pertinent secondary diagnoses that included Age-related OA with current pathological fracture, delayed healing; acute diastolic (congestive) heart failure, history of falls, lumbosacral plexus disorders, and Type 2 Diabetes Mellitus with diabetic neuropathy. On 1/7/2025, 55 days after the first day of Benefit Period 7 (effective 11/13/2024 to 01/11/2025), the Medical Director signed a Word document with typed clinical findings that DPCS stated was a Certification of Terminal Illness for Benefit Period 7. When the Medical Director was asked how the Word document was created and when he had composed the narrative, he was unable to articulate the process of how or when the document was composed but stated he came to the office to sign documents as requested.”

“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 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 CONTINUING CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records, interviews, and review of records with the Administrator and the Director of Patient Care Services Designee which revealed continuing issues with the lack of documented evidence regarding the development and implementation of patients’ interdisciplinary care plans in the following areas: Failure to ensure the plan of care reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments [HCPC.21.I/L545]; Failure to ensure the revised plan of care included information from the patient’s updated comprehensive assessment [HCPC.22.I/L553]; Failure to ensure Interdisciplinary group reviewed, revised, and documented the individualized care plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days [HCPC.22.I/L552]; and Failure to ensure hospice care and services were provided in accordance with the patient plan of care [HCPC.23.D/L555]. HCPC.22.I/L552 is a continuing required action, which was cited on the renewal visit of 10/09/2024 for 4/4 (100%) clinical records with incomplete documentation of interdisciplinary group (IDG) review of the plan of care no less frequently than every 15 calendar days and is recited in this review with 4/4 (100%) clinical records with incomplete documentation of IDG review of the plan of care at lease every 15 days. 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 a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by clinical record review, interviews, and review of findings with the Administrator and Director of Patient Care Services Designee, which revealed the following issues regarding Hospice Aide services: Failure to ensure the Registered Nurse prepared written patient specific care instructions for the Hospice Aide [HCDT.15.I/L625] and Failure to ensure the Hospice Aide documented services were provided as ordered in the aide care plan [HCDT.16.I/L626]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving home health care service from the agency.”

“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 4 of 4 (100%) clinical records reviewed, the agency did not ensure the plan of care reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 08/10/2023 and was most recently recertified for the episode of care dated 10/03/2024 to 12/01/2024. The Social Worker (SW) completed an assessment on 10/26/2024 that include a projected frequency of SW visits one time per month. The updated plan of care dated 10/29/2024 included interventions and goals for nursing services in the Problem List section, but the plan of care did not include patient specific goals and interventions for psychosocial services provided by the Social Worker. Clinical Record 2: The patient elected the hospice benefit on 05/17/2024 and was most recently recertified for the episode of care dated 11/13/2024 to 01/11/2025. The SW completed an assessment on 10/26/2024 that include a projected frequency of SW visits one time per month. The updated plan of care dated 10/29/2024 included interventions and goals for nursing services in the Problem List section, but the plan of care did not include patient specific goals and interventions for psychosocial services provided by the Social Worker. Clinical Record 3: The patient elected the hospice benefit on 07/13/2023 and was most recently recertified for the episode of care dated 11/04/2024 to 01/02/2025. The SW completed an assessment on 10/26/2024 that include a projected frequency of SW visits one time per month. The updated plan of care dated 10/29/2024 included interventions and goals for nursing services in the Problem List section, but the plan of care did not include patient specific goals and interventions for psychosocial services provided by the Social Worker. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023 and was most recently recertified for the episode of care dated 10/31/2024 to 12/29/2024. The SW completed an assessment on 10/26/2024 that include a projected frequency of SW visits one time per month. The updated plan of care dated 10/29/2024 included interventions and goals for nursing services in the Problem List section, but the plan of care did not include patient specific goals and interventions for psychosocial services provided by the Social Worker. During an interview while performing joint clinical record audits on 11/15/2024, the Director of Patient Care Services (DPCS) Designee stated, “We are still learning the electronic medical record (EMR). The DPCS that knows the EMR better will be returning on 11/21/2024. I did find the “Problem List” with the associated goal(s) and intervention(s) but the only ones listed were for nursing. The Social Worker just started on 10/21/2024 and was still learning the EMR.” The DPCS Designee talked with the Social Worker by phone and when asked about entering problem(s), goal(s), and intervention(s) he mentioned the Social Worker stated, “I’m still learning how to work the EMR. I have not added any, but I plan to add them.””

“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 IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 4 (100%) clinical records reviewed, the agency did not ensure the Interdisciplinary group (IDG) reviewed, revised, and documented the individualized care plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. Clinical Record 1: The patient elected the hospice benefit on 08/10/2023 and was most recently recertified for the episode of care dated 10/03/2024 to 12/01/2024. Clinical record review revealed that IDT (Interdisciplinary Team) meetings were scheduled in the electronic medical record (EMR) on 10/18/2024, 10/22/2024, and 11/05/2024. The status of the 10/18/2024 IDT meeting was listed as “Signed” in the EMR. The 10/18/2024 IDG meeting included a comprehensive assessment update from the nurse dated 10/17/2024 but the assessment updates from the Social Worker and Chaplin were left blank. The 10/22/2024 and 11/05/2024 IDT meetings were listed as “Not Started” in the EMR. As of the date of record review on 11/15/2024, the clinical record included no documented evidence that the IDT reviewed and revised the plan of care every 15 days, when the IDT meeting documentation was incomplete in the clinical record. Clinical Record 2: The patient elected the hospice benefit on 05/17/2023 and was most recently recertified for the episode of care dated 11/13/2024 to 01/11/2025. Clinical record review revealed that IDT meetings were scheduled in the EMR on 10/18/2024, 10/22/2024, and 11/05/2024. The status of the 10/18/2024 IDT meeting was listed as “Signed” in the EMR. The 10/18/2024 IDG meeting included a comprehensive assessment update from the nurse dated 10/17/2024 but the assessment updates from the Social Worker and Chaplin were left blank. The 10/22/2024 and 11/05/2024 IDT meetings were listed as “Not Started” in the EMR. As of the date of record review on 11/15/2024, the clinical record included no documented evidence that the IDT reviewed and revised the plan of care every 15 days, when the IDT meeting documentation was incomplete in the clinical record. Clinical Record 3: The patient elected the hospice benefit on 07/13/2023 and was most recently recertified for the episode of care dated 11/04/2024 to 01/02/2025. Clinical record review revealed that IDT meetings were scheduled in the EMR on 10/18/2024, 10/22/2024, and 11/05/2024. The status of the 10/18/2024 IDT meeting was listed as “Signed” in the EMR. The 10/18/2024 IDG meeting included a comprehensive assessment update from the nurse dated 10/17/2024 but the assessment updates from the Social Worker and Chaplin were left blank. The 10/22/2024 and 11/05/2024 IDT meetings were listed as “Not Started” in the EMR. As of the date of record review on 11/15/2024, the clinical record included no documented evidence that the IDT reviewed and revised the plan of care every 15 days, when the IDT meeting documentation was incomplete in the clinical record. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023 and was most recently recertified for the episode of care dated 10/31/2024 to 12/29/2024. Clinical record review revealed that IDT meetings were scheduled in the EMR on 10/18/2024, 10/22/2024, and 11/05/2024. The status of the 10/18/2024 IDT meeting was listed as “Signed” in the EMR. The 10/18/2024 IDG meeting included a comprehensive assessment update from the nurse dated 10/17/2024 but the assessment updates from the Social Worker and Chaplin were left blank. The 10/22/2024 and 11/05/2024 IDT meetings were listed as “Not Started” in the EMR. As of the date of record review on 11/15/2024, the clinical record included no documented evidence that the IDT reviewed and revised the plan of care every 15 days, when the IDT meeting documentation was incomplete in the clinical record. The Director of Patient Care Services Designee provided three IDT sign-in sheets for IDT meetings held on 10/15/2024, 10/29/2024, and 11/12/2024. The 11/12/2024 sign-in sheet included signatures from the hospice core team, which included the physician, the Spiritual Counselor/Bereavement Coordinator, Medical Social Worker, and the Registered Nurse. In the EMR the IDT meetings were dated 10/18/2024, 10/22/2024, and 11/05/2024. The dates listed on the IDT sign-in sheets did not match the dates the IDT meetings were documented in the EMR. During an interview on 11/15/2024, the Director of Patient Care Services (DPCS) Designee shared with this site visitor that the agency had IDT meetings on 10/15/2024, 10/29/2024, and 11/12/2024 and had meeting sign-in sheets for each of the IDT meetings. The DPCS Designee stated, “I don’t know why the dates don’t match up with the “IDT Tab” in the EMR.” This site visitor asked if there were notes on paper that would suffice for the updates. The DPCS Designee stated, “I’m not able to find any, but I know we met.” During an interview on 11/15/2024, the Administrator and Director of Patient Care Services Designee confirmed the IDT documentation was not completed timely, and the records did not show documentation that the IDT meetings occurred at lease every 15 days and there was no documentation to verify the exact date of the IDT meetings.”

“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. A revised plan of care includes information from the patient’s updated comprehensive assessment, and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and observation. In 4 of 4 (100%) clinical records reviewed, the agency did not ensure the revised plan of care included information from the patient’s updated comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 08/10/2023 and was most recently recertified for the episode of care dated 10/03/2024 to 12/01/2024. Clinical record review revealed that IDT (Interdisciplinary Team) meetings were scheduled on 10/18/2024, 10/22/2024, and 11/05/2024. The status of the 10/18/2024 IDT meeting was listed as “Signed” in the electronic medical record (EMR). The 10/18/2024 IDG meeting included a comprehensive assessment update from the nurse dated 10/17/2024 but the assessment updates from the Social Worker and Chaplin were left blank. The 10/22/2024 and 11/05/2024 IDT meetings were listed as “Not Started” in the EMR and the assessment updates were not documented. As of the date of record review on 11/15/2024, the clinical record included no documented evidence that the IDT, including the Registered Nurse, Social Worker, and Chaplain completed ongoing interdisciplinary comprehensive assessments. Clinical Record 2: The patient elected the hospice benefit on 05/17/2024 and was most recently recertified for the episode of care dated 11/13/2024 to 01/11/2025. Clinical record review revealed that IDT meetings were scheduled for 10/18/2024, 10/22/2024, and 11/05/2024. The status of the 10/18/2024 IDT meeting was listed as “Signed” in the EMR. The 10/18/2024 IDG meeting included a comprehensive assessment update from the nurse dated 10/17/2024 but the assessment updates from the Social Worker and Chaplin were left blank. The 10/22/2024 and 11/05/2024 IDT meetings were listed as “Not Started” in the EMR and the assessment updates were not documented. As of the date of record review on 11/15/2024, the clinical record included no documented evidence that the IDT, including the Registered Nurse, Social Worker, and Chaplain completed ongoing interdisciplinary comprehensive assessments. Clinical Record 3: The patient elected the hospice benefit on 07/13/2023 and was most recently recertified for the episode of care dated 11/04/2024 to 01/02/2025. Clinical record review revealed that IDT meetings were scheduled for 10/18/2024, 10/22/2024, and 11/05/2024. The status of the 10/18/2024 IDT meeting was listed as “Signed” in the EMR. The 10/18/2024 IDG meeting included a comprehensive assessment update from the nurse dated 10/17/2024 but the assessment updates from the Social Worker and Chaplin were left blank. The 10/22/2024 and 11/05/2024 IDT meetings were listed as “Not Started” in the EMR and the assessment updates were not documented. As of the date of record review on 11/15/2024, the clinical record included no documented evidence that the IDT, including the Registered Nurse, Social Worker, and Chaplain completed ongoing interdisciplinary comprehensive assessments. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023 and was most recently recertified for the episode of care dated 10/31/2024 to 12/29/2024. Clinical record review revealed that IDT meetings were scheduled for 10/18/2024, 10/22/2024, and 11/05/2024. The status of the 10/18/2024 IDT meeting was listed as “Signed” in the EMR. The 10/18/2024 IDG meeting included a comprehensive assessment update from the nurse dated 10/17/2024 but the assessment updates from the Social Worker and Chaplin were left blank. The 10/22/2024 and 11/05/2024 IDT meetings were listed as “Not Started” in the EMR and the assessment updates were not documented. As of the date of record review on 11/15/2024, the clinical record included no documented evidence that the IDT, including the Registered Nurse, Social Worker, and Chaplain completed ongoing interdisciplinary comprehensive assessments. During an interview while completing joint clinical record audits on 11/15/2024, the Director of Patient Care Services Designee stated, “I don’t know why there was nothing listed for the other disciplines on the 10/18/2024 IDT notes, and I don’t know why the notes for 10/22/2024 and 11/05/2024 are “Not Started.” During an interview and record review on 11/15/2024, the Administrator and Director of Patient Care Services Designee confirmed the comprehensive assessments were not updated by the disciplines involved and documented in the IDT meetings.”

“It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that: care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (100%) clinical records reviewed, the agency did not ensure care and services were provided in accordance with the patient plan of care. Clinical Record 3: The patient elected the hospice benefit on 07/13/2023. The recertification plans of care dated 09/05/2024 to 11/03/2024 and 11/04/2024 to 01/02/2025 both included a physician order for nursing frequency 1 visit every 2 weeks and 1 as needed visit for symptom management. The Registered Nurse (RN) documented a nursing visit on 10/17/2024 and the next nursing visit was dated 11/07/2024, 21 days after the 10/17/2024 nursing visit. The clinical record contained no documented evidence of a reason for the missed nursing visit or that the physician and IDG [interdisciplinary group] were notified of the missed visit. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023. The recertification plans of care dated 09/01/2024 to 10/30/2024 and 10/31/2024 to 12/29/2024 both included a physician order for nursing frequency 1 visit every 2 weeks and 1 as needed visit for symptom management. The RN documented a nursing visit on 10/17/2024 and the next nursing visit was dated 11/07/2024, 21 days after the 10/17/2024 nursing visit. The clinical record contained no documented evidence of a reason for the missed nursing visit or that the physician and IDG [interdisciplinary group] were notified of the missed visit.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse (RN) prepared written patient specific care instructions for the Hospice Aide (HA). Clinical Record 1: The patient elected the hospice benefit on 08/10/2023 and was most recently recertified for the episode of care dated 10/03/2024 to 12/01/2024. Clinical record review revealed the HA provided an aide visit to the patient on 10/26/2024. The aide care plan assignment prepared by the RN was dated 11/01/2024, six days after the aide visit was completed. The HA provided an aide visit to the patient prior to the aide care plan assignment being completed. During an interview on 11/15/2024 the Hospice Aide was asked how she knew what tasks were ordered for the 10/26/2024 aide visit she completed. The aide was asked if there was an aide care plan assignment to follow. The aide replied “No, the RN told me what I needed to do on the phone.” Clinical Record 3: The patient elected the hospice benefit on 07/13/2023 and was most recently recertified for the episode of care dated 11/04/2024 to 01/02/2025. Clinical record review revealed the HA provided an aide visit to the patient on 10/26/2024. The aide care plan assignment prepared by the RN was dated 11/01/2024, six days after the aide visit was completed. The HA provided an aide visit to the patient prior to the aide care plan assignment being completed by the RN. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023 and was most recently recertified for the episode of care dated 10/31/2024 to 12/29/2024. Clinical record review revealed the HA provided an aide visit to the patient on 10/26/2024. The aide care plan assignment prepared by the RN was dated 11/01/2024, six days after the aide visit was completed. The HA provided an aide visit to the patient prior to the aide care plan assignment being completed the RN. During an interview and record review on 11/15/2024, the Administrator and Director of Patient Care Services Designee stated that the written patient care instructions /aide care plan assignment was not prepared by a RN prior to the aide providing a visit to the patient.”

“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 3 of 3 (100%) clinical records reviewed with aide services provided, the agency did not ensure the Hospice Aide (HA) documented services were provided as ordered in the aide care plan. Clinical Record 1: The patient elected the hospice benefit on 08/10/2023 and was most recently recertified for the episode of care dated 10/03/2024 to 12/01/2024. Clinical record review revealed the HA provided an aide visit to the patient on 10/26/2024. The aide visit note for the 10/26/2024 visit was not documented in the electronic medical record, as of the date of record review on 11/15/2024. The clinical record contained no documented evidence that the HA had provided services as ordered in the aide care plan. Clinical Record 3: The patient elected the hospice benefit on 07/13/2023 and was most recently recertified for the episode of care dated 11/04/2024 to 01/02/2025. Clinical record review revealed the HA provided an aide visit to the patient on 10/26/2024. The aide visit note for the 10/26/2024 visit was not documented in the electronic medical record, as of the date of record review on 11/15/2024. The clinical record contained no documented evidence that the HA had provided services as ordered in the aide care plan. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023 and was most recently recertified for the episode of care dated 10/31/2024 to 12/29/2024. Clinical record review revealed the HA provided an aide visit to the patient on 10/26/2024. The aide visit note for the 10/26/2024 visit was not documented in the electronic medical record, as of the date of record review on 11/15/2024. The clinical record contained no documented evidence that the HA had provided services as ordered in the aide care plan. During an interview and record review on 11/15/2024, the Administrator and the Director of Patient Care Services Designee agreed the clinical records did not include completed documentation for the 10/26/2024 aide visits because they were having challenges with the electronic medical record.”

“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 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 document review, review of clinical records, and interview with the Director of Patient Care Services which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure to ensure the Interdisciplinary Group, in its entirety, supervised the care and services provided to the patient and the family [HCPC.1.I/L539]; Failure to ensure the Interdisciplinary Group included an individual who was qualified and competent to practice as a Pastoral or other counselor [HCPC.2.D/L541]; Failure to ensure the Interdisciplinary Group included an individual who was qualified and competent to practice as a Social Worker, marriage and family therapist, or a mental health counselor [HCPC.2.D/L541]; and Failure to ensure the Interdisciplinary Group reviewed, revised, and documented the individualized plan of care 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 the hospice EP [emergency preparedness] training program that 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. A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by personnel record review and interview. In 6 of 8 (75%) personnel records reviewed, the agency did not ensure the employees received emergency preparedness training at least every two years. Personnel Record 1: Medical Director date of hire on 03/18/2019. The personnel file contained no documented evidence that EP training had been completed since 2021. Personnel Record 2: Administrator date of hire on 03/18/2019. The personnel file contained no documented evidence that EP training had been completed since 2021. Personnel Record 3: Director of Patient Care Services date of hire on 12/28/2020. The personnel file contained no documented evidence that EP training had been completed since 2021. Personnel Record 4: Registered Nurse date of hire on 10/18/2020. The personnel file contained no documented evidence that EP training had been completed since 2021. Personnel Record 5: Social Worker date of hire on 07/29/2021. The personnel file contained no documented evidence that EP training had been completed since 2021. Personnel Record 8: Volunteer date of hire on 02/02/2021. The personnel file contained no documented evidence that EP training had been completed since 2021. During a joint interview and personnel file review with the Administrator and Alternate Director of Patient Care Services on 10/08/2024, they confirmed the employees had not completed emergency preparedness training since the initial hospice licensure in 2021 and had not participated in a community-based emergency preparedness drill or rehearsal, or a hospice emergency drill for “over three years.””

“It is required that the hospice Interdisciplinary Group (IDG), in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 10 of 11 (91%) clinical records reviewed, the agency did not ensure members of the IDG completed the initial comprehensive assessment no later than five calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 07/13/2023. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 05/14/2024. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 3: The patient elected the hospice benefit on 08/01/2023. Clinical record review revealed no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Spiritual Counselor, as a member of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023. Clinical record review revealed no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Spiritual Counselor, as a member of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 6: The patient elected the hospice benefit on 07/12/2023. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 7: The patient elected the hospice benefit on 01/05/2022. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 8: The patient elected the hospice benefit on03/14/2022. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 9: The patient elected the hospice benefit on 09/02/2021. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 10: The patient elected the hospice benefit on 04/12/2023. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. Clinical Record 11: The patient elected the hospice benefit on 03/18/2023. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not complete the initial comprehensive assessment no later than five calendar days after the patient’s election of hospice care. During an interview on 10/09/2024, the Director of Patient Care Services stated, “some of these might have been completed but documentation has been an issue, and we have an open PIP (performance improvement project).””

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 11 (64%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023. Clinical record review revealed no documented evidence that a bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 5: The patient elected the hospice benefit on 09/28/2021. Clinical record review revealed no documented evidence that a bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 7: The patient elected the hospice benefit on 01/05/2022. Clinical record review revealed no documented evidence that a bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 8: The patient elected the hospice benefit on 03/14/2022. Clinical record review revealed no documented evidence that a bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 9: The patient elected the hospice benefit on 09/02/2021. Clinical record review revealed no documented evidence that a bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 04/12/2023. Clinical record review revealed no documented evidence that a bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 11: The patient elected the hospice benefit on 03/18/2023. Clinical record review revealed no documented evidence that a bereavement assessment was completed as part of the comprehensive assessment. During an interview on 10/09/2024, the Director of Patient Care Services stated, “she believed some of these had been completed as the staff had come out on the admission with her, but they had a big issue with documentation.””

“It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by document review, clinical record review and interview. In 10 of 11 (91%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group (IDG), in its entirety, supervised the care and services provided to the patient and the family. Clinical Record 1: The patient elected the hospice benefit on 07/13/2023. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 2: The patient elected the hospice benefit on 05/14/2024. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 3: The patient elected the hospice benefit on 08/01/2023. Clinical record review revealed no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Spiritual Counselor, as a member of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 4: The patient elected the hospice benefit on 09/07/2023. Clinical record review revealed no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Spiritual Counselor, as a member of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 6: The patient elected the hospice benefit on 07/12/2023. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 7: The patient elected the hospice benefit on 01/05/2022. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 8: The patient elected the hospice benefit on03/14/2022. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 9: The patient elected the hospice benefit on 09/02/2021. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 10: The patient elected the hospice benefit on 04/12/2023. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Clinical Record 11: The patient elected the hospice benefit on 03/18/2023. Clinical record review revealed no documented evidence that the Social Worker completed a psychosocial assessment as part of the initial comprehensive assessment and there was no documented evidence that the Spiritual Counselor completed a spiritual assessment as part of the initial comprehensive assessment. The Social Worker and the Spiritual Counselor, as members of the IDG, did not participate in supervising the care and services of the patient and family at the start of care. Review of documentation of Interdisciplinary Group (IDG) Meetings held from December 2023 to October 2024 revealed no documented evidence that a Social Work and Pastoral/Spiritual Counselor were present and participated at the IDG meetings and there was no documented evidence that the Social Worker and Pastoral/Spiritual Counselor supervised the care and services provided to the patient and family. During an interview on 10/09/2024, the Director of Patient Care Services discussed the agency’s process for supervising the patients care and services and stated there were “many [IDG] meetings where all the disciplines were unable to attend, and the meeting mostly consisted of herself as the nurse and the hospice medical director discussing the patients on the telephone.” She further stated the attendance by the Social Worker and Spiritual Counselor has been “sporadic since the end of 2023” and this was due to the “loss of the Spiritual Counselor due to death and decrease in patients, along with staff working other jobs.” A review of Clinical Records # 1 through #11 on 10/08/2024 and 10/09/2024, revealed only the Registered Nurse and the Medical Director were documenting the review, revision, and supervision of the care and services provided to the patient and family every 15 days. The last documentation of the entire Interdisciplinary Group including the Hospice Medical Director, Registered Nurse, Social Worker, and Spiritual Counselor meeting was in December 2023.”

“It is required that the hospice Interdisciplinary Group includes, but is not limited to, individuals who are qualified and competent to practice in the following professional roles: Doctor of Medicine or Osteopathy (who is an employee or under contract with the hospice), Registered Nurse, Social Worker, marriage and family therapist, or a mental health counselor, and Pastoral or other counselor(s). This standard was not met as evidenced by document review and interview. The agency did not ensure Interdisciplinary Group (IDG) included an individual who was qualified and competent to practice as a Social Worker, marriage and family therapist, or a mental health counselor. Review of documentation of Interdisciplinary Group (IDG) Meetings held from December 2023 to October 2024 revealed no documented evidence that a Social Worker or family therapist was present and participated at the IDG meetings. During an interview on 10/09/2024, the Director of Patient Care Services discussed the process of the IDG meetings, stated there were “many meetings where all the disciplines were unable to attend, and the meeting mostly consisted of herself as the nurse and the hospice medical director discussing the patients on the telephone.” She further stated the attendance by the Social Worker and Spiritual Counselor has been “sporadic since the end of 2023” and this was due to the “loss of the Spiritual Counselor due to death and decrease in patients, along with staff working other jobs.” The Interdisciplinary Group (IDG) Meetings held from December 2023 to October 2024 have not included documentation of a Social Worker being present at the meetings.”

“It is required that the hospice Interdisciplinary Group includes, but is not limited to, individuals who are qualified and competent to practice in the following professional roles: Doctor of Medicine or Osteopathy (who is an employee or under contract with the hospice), Registered Nurse, Social Worker, marriage and family therapist, or a mental health counselor, and Pastoral or other counselor(s). This standard was not met as evidenced by document review and interview. The agency did not ensure Interdisciplinary Group (IDG) included an individual who was qualified and competent to practice as a Pastoral or other counselor. Review of documentation of Interdisciplinary Group (IDG) Meetings held from December 2023 to October 2024 revealed no documented evidence that a Pastoral or Spiritual Counselor was present and participated at the IDG meetings. During an interview on 10/09/2024, the Director of Patient Care Services discussed the process of the IDG meetings, stated there were “many meetings where all the disciplines were unable to attend, and the meeting mostly consisted of herself as the nurse and the hospice medical director discussing the patients on the telephone.” She further stated the attendance by the Social Worker and Spiritual Counselor has been “sporadic since the end of 2023” and this was due to the “loss of the Spiritual Counselor due to death and decrease in patients, along with staff working other jobs.” The Interdisciplinary Group (IDG) Meetings held from December 2023 to October 2024 have not included documentation of a Spiritual Counselor being present at the meetings.”

“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 4 of 4 (100%) clinical records review, the agency did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the individualized plan of care no less frequently than every 15 calendar days. Clinical Record 1: Clinical record review revealed the IDG reviewed, revised, and documented a plan of care review on 09/17/2024. The next IDG review was dated 10/09/2024, a total of 21 days and 7 days outstanding. Clinical Record 2: Clinical record review revealed the IDG reviewed, revised, and documented a plan of care review on 09/17/2024. The next IDG review was dated 10/09/2024, a total of 21 days and 7 days outstanding. Clinical Record 3: Clinical record review revealed the IDG reviewed, revised, and documented a plan of care review on 09/17/2024. The next IDG review was dated 10/09/2024, a total of 21 days and 7 days outstanding. Clinical Record 4: Clinical record review revealed the IDG reviewed, revised, and documented a plan of care review on 09/17/2024. The next IDG review was dated 10/09/2024, a total of 21 days and 7 days outstanding. During an interview with the Director of Patient Care Services (DPCS) on 10/09/2024 to discuss the IDG process. The DPCS stated, “We missed one last week because the doctor was busy.””

“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 5 of 8 (62%) personnel records reviewed, the agency did not ensure ongoing employee education related to the hospice’s infection control program. Personnel Record 1: Medical Director date of hire 03/18/2019. Review of the personnel record revealed no documented evidence of infection control education for 2022 and 2023. Personnel Record 3: Director of Patient Care Services date of hire 12/28/2020. Review of the personnel record revealed no documented evidence of infection control education for 2022 and 2023. Personnel Record 4: Registered Nurse date of hire 10/18/2020. Review of the personnel record revealed no documented evidence of infection control education for 2022 and 2023. Personnel Record 5: Social Worker date of hire 07/29/2021. Review of the personnel record revealed no documented evidence of infection control education for 2022 and 2023. Personnel Record 8: Volunteer date of hire 02/02/2021. Review of the personnel record revealed no documented evidence of infection control education for 2022 and 2023. During a joint interview and personnel file review with the Administrator and Alternate Director of Patient Care Services on 10/08/2024, they confirmed the infection control education had not been completed since the initial hospice licensure in 2021.”

“It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 6 of 7 (86%) clinical records reviewed with bereavement services required, the agency did not ensure the bereavement plan of care was developed for the bereaved. Clinical Record 5: The patient elected the hospice benefit on 09/28/2021 and expired on 11/27/2023. Clinical record review revealed a bereavement plan of care that included the types of services to be offered, and the frequency of service delivery had not been developed for the bereaved. Clinical Record 6: The patient elected the hospice benefit on 07/12/2023 and expired on 11/09/2023. Clinical record review revealed a bereavement plan of care that included the types of services to be offered, and the frequency of service delivery had not been developed for the bereaved. Clinical Record 7: The patient elected the hospice benefit on 01/05/2022 and expired on 10/06/2022. Clinical record review revealed a bereavement plan of care that included the types of services to be offered, and the frequency of service delivery had not been developed for the bereaved. Clinical Record 9: The patient elected the hospice benefit on 09/02/2021 and expired on 06/01/2023. Clinical record review revealed a bereavement plan of care that included the types of services to be offered, and the frequency of service delivery had not been developed for the bereaved. Clinical Record 10: The patient elected the hospice benefit on 04/12/2023 and expired on 09/06/2023. Clinical record review revealed a bereavement plan of care that included the types of services to be offered, and the frequency of service delivery had not been developed for the bereaved. Clinical Record 11: The patient elected the hospice benefit on 03/18/2023 and expired on 06/14/2023. Clinical record review revealed a bereavement plan of care that included the types of services to be offered, and the frequency of service delivery had not been developed for the bereaved. During an interview on 10/09/2024, the Director of Patient Care Services stated, “the previous Bereavement Coordinator had passed away and although some of the items had been completed, there has been no documentation in the clinical record.””

“It is required that volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed with volunteer services requested, the agency did not ensure volunteer services were noted in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 07/13/2023. The nursing assessment dated 05/14/2024 included documentation that the patient accepted volunteer services 1-2 times per month. The plan of care did not include interventions for the types of care and services the volunteer would provide to the patient. Clinical Record 6: The patient elected the hospice benefit on 07/12/2023. The initial nursing assessment dated 07/12/2024 included documentation that the patient accepted volunteer services 1-2 times per month. The plan of care did not include interventions for the types of care and services the volunteer would provide to the patient. Clinical Record 9: The patient elected the hospice benefit on 09/02/2021. The initial nursing assessment dated 09/02/2021 included documentation that the patient accepted volunteer services 1-2 times per month. The plan of care did not include interventions for the types of care and services the volunteer would provide to the patient. Clinical Record 11: The patient elected the hospice benefit on 03/18/2023. The initial nursing assessment dated 03/18/2023 included documentation that the patient accepted volunteer services 1-2 times per month. The plan of care did not include interventions for the types of care and services the volunteer would provide to the patient. During an interview with the Director of Patient Care Services on 10/09/2024, she confirmed that the volunteer services to be performed had not been added to the patient’s plan of care. She questioned what type of items should be placed there and stated the volunteers were “helping with errands, socialization, and other items after she completed her visits.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, personnel record review, and interview. In 5 of 8 (62%) personnel records reviewed, the agency did not ensure staff skills and competencies were assessed per agency policy. Agency policy No. 3-001 Competency Program, revised April 2020, required in part “The organization will clearly identify and define the skills which are essential to observe for the determination of competence, for each job category in the identification of core competence, the essential skills will be demonstrated upon hire and annually thereafter. 8. After completion of orientation competency will be monitored annually as part of the annual performance evaluation process.” Personnel Record 1: Medical Director date of hire on 03/18/2019. The personnel file contained no documented evidence that annual skills and competencies were assessed for 2022 or 2023. Personnel Record 3: Director of Patient Care Services date of hire on 12/28/2020. The personnel file contained no documented evidence that annual skills and competencies were assessed for 2022 or 2023. Personnel Record 4: Registered Nurse date of hire on 10/18/2020. The personnel file contained no documented evidence that annual skills and competencies were assessed for 2022 or 2023. Personnel Record 5: Social Worker date of hire on 07/29/2021. The personnel file contained no documented evidence that annual skills and competencies were assessed for 2022 or 2023. Personnel Record 8: Volunteer date of hire on 02/02/2021. The personnel file contained no documented evidence that annual skills and competencies were assessed for 2022 or 2023. During a joint interview and personnel file review with the Administrator and Alternate Director of Patient Care Services on 10/08/2024, they confirmed the competencies and skills check lists had not been completed since the initial hospice licensure in 2021.”