St Martin High Desert

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records revealed the agency did not ensure the initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/12/2024. The social worker (SW) noted on 07/16/2024 “called and left VM (voicemail)”. The SW called on 07/19/2024 and noted “that patient agreed to 07/20/2024.” The SW initial assessment was completed on 07/21/2024, nine days after the election of the hospice benefit. CLINICAL RECORD 4: Patient elected the hospice benefit on 10/15/2024. The initial spiritual assessment was completed on 10/25/2024, 10 days after the election of the hospice benefit. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/12/2024. The social worker completed the initial SW assessment on 06/21/2024, 9 days after the election of the hospice benefit. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/03/2023. The spiritual counselor called the patient on 02/04/2023, 02/06/2023 and 02/011/2023 and left voicemails. The initial assessment was completed on 03/06/2023, 31 days after the election of the hospice benefit. CLINICAL RECORD 13: The patient elected the hospice benefit on 12/10/2024. The spiritual counselor completed the initial assessment on 12/17/2024, 7 days after the election of the hospice benefit. An interview and joint clinical record review was conducted with the Administrator on 02/06/2025. She responded that the staff was “supposed to include the reason why they were late with the visits in their communication notes, not just that they called.””

“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. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) home visits revealed the agency did not ensure the drug profile contained the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Home Visit 3: The patient elected the hospice benefit on 12/12/2024 for secondary malignant neoplasm of brain. The patient resided in a board and care home. During a home visit with the Social Worker (Personnel Record 2) on 02/06/2025, the hospice medication profile (printed on 02/05/2025) was compared to the board and care home medication list (printed on 02/06/2025). The following discrepancies were noted: The board and care listed Albuterol Sulfate 0.083% solution 1 dose three times a day as needed. The hospice medication list documented the Albuterol Sulfate 0.083% solution as three times a day scheduled. The “as needed” dose was the correct order. The board and care listed Norco 10-325 mg three times a day as needed. The hospice medication list documented the Norco as scheduled. The “as needed” dose was the correct order. An interview and joint clinical record review was conducted with the Director of Patient Care Services on 02/06/2025 and verified the medication lists had not been reconciled.”

“It is required that 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 1 of 13 (8%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 13: The hospice aide care plan dated 12/10/2024 included the following relevant tasks: shampoo, blow dry, shave, monitor skin and report changes to RN, incontinent care, bed bath, diapers and bed bath every visit. The aide frequency was three times weekly. The initial nursing assessment dated 12/10/2024 noted the patient to have continuous oxygen at 5 liters per minute and a Stage IV sacral wound pressure ulcer covered with foam dressing. The aide care plan did not include specific instructions for care of the oxygen or wound during tasks. An interview and joint clinical record review was conducted with the Director of Patient Care Services on 02/06/2025 in which she confirmed the aide plan of care lacked specific instructions for the oxygen or wound.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 13 (8%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide provided services included in the plan of care as ordered by the Interdisciplinary Group. Home Visit 1: A home visit to observe the hospice aide (Personnel Record 7) was performed on 02/06/2025. The hospice aide care plan dated 07/12/2024 included the following relevant tasks to be completed every visit: file nails, check vitals, and change patient linens. These tasks were not completed by the aide during the home visit. An interview and joint clinical record review was conducted with the Director of Patient Care Services on 02/06/2025 and she advised the task of “check vitals every visit should not have been on the care plan at all. I spoke to the aide, and she wasn’t aware she should be doing vital signs.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by clinical record review and interview. A review of the volunteer cost savings report with the Volunteer Coordinator and Administrator for 2024 revealed the volunteer percentage for 2024 was 1.04%. They advised the Volunteer Coordinator had changed from a volunteer to the coordinator in March and that had reduced “quite a few hours.” They advised they “had also lost a volunteer whose hours had become reduced when his mother became sick.” A review of the volunteer cost savings report with the Volunteer Coordinator and Administrator for 2024 revealed the volunteer percentage for 2024 was 1.04% as opposed to the required 5%. They advised the Volunteer Coordinator had changed from a volunteer to the coordinator in March and that had reduced “quite a few hours.” They advised they “had also lost a volunteer who’s hours had become reduced when his mother became sick.””

“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. This standard was not met as evidenced by clinical record review and interview. In 2 of 8 (25%) clinical records reviewed in which recertification was required revealed the agency did not ensure the hospice medical director or designee provided written and signed recertification. CLINICAL RECORD 6: The hospice medical director narrative for the recertification of terminal illness for the fourth benefit period stated, “Agree with RN narrative.” CLINICAL RECORD 8: The hospice medical director narrative for the recertification of terminal illness for the third benefit period stated, “Agree with RN narrative.” An interview and joint clinical record review was conducted with the Director of Patient Care Services on 02/06/2025 in which she stated she was “surprised he wrote that as he normally expects us to be very detailed in our narratives.””

“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 1 of 8 (12%) clinical records reviewed revealed the agency did not ensure the hospice medical director completed and signed the recertification 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. CLINICAL RECORD 10: The recertification for benefit period 12 which started on 02/01/2025 was not completed or signed as of 02/07/2025, making it 6 days late or 4 days outstanding. During an interview with the Director of Patient Care Services on 02/07/2025 she advised it “would be signed today at interdisciplinary group meeting.””