All Star Hospice Care, Inc.

“Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG- composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement) are conducted to meet the patient and family-specific needs identified in the comprehensive assessment related to the terminal illness and related conditions for 1 of 6 patients (Patient 1). This deficient practice has the potential to result in an uncoordinated care and services by the designated member of the IDG ordered in the plan of care that could result in the lack of supervision and evaluation of care provided to the hospice patient or family members. A review of Patient 1s admission record indicated the patient was admitted for hospice on 2/14/2024, with a primary diagnosis of hypertensive heart disease with heart failure. A review of Patient 1s medical record titled; “;IDT Comprehensive Assessment” indicated as follows: During the IDT meeting dated 2/23/2024, 2/24/2024, 3/4/2024, 3/18/2024, 4/1/2024, and 4/15/2024, IDT members who updated/reviewed the Interdisciplinary Team Plan of Care of Patient 1 indicated both the Registered Nurse and the Hospice Physician signed indicating both were present at the meeting these dates. The Spiritual Counselor, Social Worker, Volunteer Coordinator services were missing signatures indicating they did not attend the meeting. During an interview with the Director of Patient Care Services (DPCS) on 4/25/2024 at 12:30 p.m., DPCS asked how often the IDT meetings were conducted. DPCS stated every other week. DPCS also stated that the Administrator, Medical Director, Social worker, Volunteer coordinator, Chaplain and skilled nursing are members of the IDT. DPCS was also asked when the next scheduled IDT meeting will be, DPCS stated “ It was supposed to be today but DPH is here so we will move it after your exit”. A review of the HAs policy titled “ Interdisciplinary Group Meeting” revised 11/2021 indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. The meeting will be facilitated by the hospice Clinical Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.”

“Based on interview and record review, the hospice agency (HA) failed to develop an individualized plan of care (POC, a form where you can summarize patients health conditions, specific care needs, goals, and current treatments) with measurable objectives, timeframe, and interventions to meet the hospice patients’ needs for four out of six sampled patients (Patients 2, 3, 5 and 6). This deficient practice resulted in the patients not having a plan of care identifying all care and services necessary in the palliation (relief) and management of the terminal illness and related conditions. a. During a close record review of Patient 2’s admission record indicated a start of care date of 5/28/23, with a terminal diagnosis of hypertensive heart disease (constellation of changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 2’s Comprehensive Assessment, dated 5/28/23, indicated Patient 2 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 2 had mild dyspnea (shortness of breath) with mild exertion, needs moderate assistance with toileting and transfer, and maximum assistance with bathing and ambulation. During a review of Patient 2s clinical record, the clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. b. During a closed record review of Patient 3’s admission record indicated a start of care date of 8/9/2022, with a terminal diagnosis of cardiovascular heart disease (heart conditions that include diseased vessels, structural problems and blood clots). During a review of Patient 3’s Comprehensive Assessment, dated 8/9/2022, indicated Patient 3 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 3 had periods of shortness of breath with moderate exertion, needed moderate assistance with ADLs (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), at moderate risk for falls, had tachycardia (fast heart rate), and had increased respirations (breathing) due to severe pain. During a review of Patient 3s clinical record, the clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. c. During a close record review of Patient 5’s admission record indicated a start of care date of 2/13/2022, with a terminal diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 5s clinical record, the clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. d. During a close record review of Patient 6’s admission record indicated a start of care date of 5/28/2023, with a terminal diagnosis of cardiovascular heart disease (heart conditions that include diseased vessels, structural problems and blood clots). During a review of Patient 6’s Comprehensive Assessment, dated 5/28/2023, indicated Patient 6 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on cane for ambulation. Patient 6 had mild dyspnea (shortness of breath) with mild exertion, needs moderate assistance with toileting and transfer, and maximum assistance with bathing and ambulation. During a review of Patient 6s clinical record, the clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. During an interview and concurrent record review on 4/26/2024, at 12:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS acknowledged the plans of care were completed that included the measurable goals to be achieved, timeframe, and interventions were not developed for Patients 2, 3, 5 and 6. During a review of the agency’s undated policy and procedure titled, “Interdisciplinary Group Membership and Responsibilities”, indicated the interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. The interdisciplinary group responsibilities include but are not limited to participation in the establishment of the plan of care for each patient admitted to the hospice services, and 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 (HA) failed to ensure patients’ written plans of care (POC) were reviewed and revised by the interdisciplinary group (IDG, a group of health care professionals with various areas of expertise responsible for the holistic care of the hospice beneficiary) no less frequently than every 15 days for four of six sampled patients (Patients 2, 3, 5, and 6). This deficient practice had a potential to result in lacking continuous assessment and care planning that meet patients’ needs. a. During a close record review of Patient 2’s admission record indicated a start of care (SOC) date of 5/28/23, with a terminal diagnosis of hypertensive heart disease (constellation of changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a further review of Patient 2’s clinical record indicated no documented evidence that the POC/IDG meeting was conducted since the SOC of 5/28/2023. b. During a closed record review of Patient 3’s admission record indicated a start of care date of 8/9/2022, with a terminal diagnosis of cardiovascular heart disease (heart conditions that include diseased vessels, structural problems and blood clots). During a further review of Patient 3’s clinical record indicated no documented evidence that the POC/IDG meeting was conducted since the SOC of 8/9/2022. c. During a close record review of Patient 5’s admission record indicated a start of care date of 2/13/2022, with a terminal diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During a further review of Patient 5’s clinical record indicated no documented evidence that the POC/IDG meeting was conducted since the SOC of 2/13/2022. d. During a close record review of Patient 6’s admission record indicated a start of care date of 5/28/2023, with a terminal diagnosis of cardiovascular heart disease (heart conditions that include diseased vessels, structural problems and blood clots). During a further review of Patient 6’s clinical record indicated no documented evidence that the POC/IDG meeting was conducted since the SOC of 5/28/2023. During an interview on 4/26/2024, at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS was not able to provide documented evidence that the POC/IDG meetings were held every 15 days for Patients 2, 3, 5 and 6 since their admission to the hospice service. A review of the HA’s policy, titled “Interdisciplinary Group Membership Responsibilities”, revised May 2022, indicated the interdisciplinary group will collaborate with the patient’s attending physician to develop an individualized written plan of care. When there is more than one (1) interdisciplinary group, the hospice will designate in advance the group responsible for program oversight and the establishment of policies that govern the day-to-day provision of hospice care and services. The hospice interdisciplinary group membership includes at a minimum: Physician, Registered Nurse, Social Worker and Pastoral or other counselor. A review of the HA’s undated policy, titled “ Interdisciplinary Coordination of Care”, indicated hospice agency personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. When the patient requires services from the interdisciplinary group, the Case Manager will be responsible for cooperative care planning to assure goals, interventions, and outcomes are palliative in nature. Written evidence of care coordination will be found in the plan of care and/or inter­disciplinary team meeting forms in the patient’s clinical record, and will involve the hospice patient’s attending physician. A review of the agencys undated policy and procedure titled, “;Interdisciplinary Group Meeting”, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, death and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires.”

“Based on interview and record review, the hospice agency failed to ensure a performance improvement projects (PIP, a concentrated effort on a particular problem in one area of the facility or facility wide involving gathering of information systematically to clarify issues or problems, and intervening for improvements) conducted every year. This failure had the potential to affect the highest quality of care provided to all the patients under the hospice agency’s care. On 4/25/2024, at 3:30 p.m., the team requested from the Director of Patient Care Services (DPCS) performance improvement projects (PIP) derived from the data collected from the Quality Assurance and Performance Improvement (QAPI, the coordinated application of two mutually‑reinforcing aspects of a quality management system. QAPI takes a systematic, comprehensive, and data‑driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program. On 4/26/2024 at 2 p.m., during a joint interview with the DPCS and the Administrator stated she was aware of the requirement, but she was not in charge of the QAPI and PIP. DPCS stated that she comes to work 2 times a week and they have entrusted a consultant to do the QA. A review of the agency’s QAPI/PIP did not indicate that the governing body discussed their QAPI/PIP as evidenced by only the Director of Patient care Services (DPCS) signed the meeting. Team members of the agency’s governing body did not attend the meeting. The agency’s policy and procedure titled “Quality Assessment and Performance Improvement Plan and Program” indicated the agency will have an organized system assessing and improving the quality of care and services. This system shall be designed to improve performance on a systematic and continuous basis. The policy stated there should be coordination of performance improvement activities.”

“Based on observation and interview, the hospice agency (HA) failed to ensure the visiting nurse (VN 1) implemented the acceptable standards of practice to prevent the transmission of infection by performing proper hand hygiene while providing direct patient care for one of 6 patients (Patient 1). This deficient practice had the potential for increase in transmission of infection and communicable diseases to the already compromised patient’s health status. A review of Patient 1’s “Patient Referral Intake” indicated, a start of care (SOC) date of 2/14/2024, with a diagnosis that included heart disease with heart failure (a condition where there is thickening of the walls of the heart due to increased blood pressure) During a review of Patient 5’s Plan of Care (POC), for the re-certification period from 12/9/2023 to 3/7/2024, included an order for Skilled Nursing (SN) to visit once a week plus 2 visits as needed. Medical Social Worker (MSW) and Chaplain once a month, Hospice aide for comfort measures only. Hospice to monitor for alteration in cardiovascular status, alteration in comfort, medication education, home safety, spiritual and socio-emotional status, support and counseling for grieving process, caregiver and family concerns. A joint home visit was conducted on 4/25/2024 at 11:55 a.m., at Patient 1s residence with Visiting Nurse 1. VN 1 stated this was his first time visiting this patient and was just covering for the nurse who regularly visits the patient. On concurrent observation. During the visit it was observed VN 1, while providing care to the patient did not perform proper hand hygiene, did not wear a mask, and did not wear gloves during this visit for the patient. During an interview with VN 1 on 4/25/2024 at 12:40 p.m., VN 1 stated that he only has one patient for this agency and was currently working for another agency’s as well. VN 1 stated that he had 5 patients to visit today, and he came from another patient where he performed wound care. VN 1 stated that Patient 1 was his third patient for today. VN 1 stated that it was his personal preference not to wear a mask and stated that the agency’s policy allowed personal preference whether to wear or not wear a mask. VN 1 also stated that he used an alcohol based hand rub in between home visits and does not want to use the patient’s or family’s soap or use any of their stuff for handwashing. VN 1 stated he encountered a family that told and asked him “Why don’t you bring your own stuff for handwashing?” and stated that he used an alcohol based hand rub instead. During an interview with the Director of Patient Care Services (DPCS) on 4/26/2024 at 12:50 p.m., DPCS stated that the visiting nurse should perform hand hygiene in between patient care and when hands are visibly soiled to prevent the spread of infection. A review of the HA’s document titled “ Standard Precautions” dated 10/2022 indicated hand hygiene will be performed to prevent cross-contamination between the patient and the personnel.”

“Based on interview and record review the hospice agency (HA) failed to ensure a process of tracking, documenting, implementing their policies and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) and providing education of infection control all HA staff, patients and their families. This deficient practice had the potential to result in placing employees, patients and their families at risk for spreading and/or contracting COVID-19 infection, that could lead to severe respiratory illness, hospitalization and/or death. A review of Patient 1’s “Patient Referral Intake” indicated, an start of care (SOC) date of 2/14/2024, with a diagnosis that included heart disease with heart failure (a condition where there is thickening of the walls of the heart due to increased blood pressure) During a review of Patient 1’s Plan of Care (POC), included an order for Skilled Nursing (SN) to visit once a week plus 2 visits as needed. Medical Social Worker (MSW) and Chaplain once a month, hospice aide refused and for comfort measures only. Hospice to monitor for alteration in cardiovascular status, alteration in comfort, medication education, home safety, spiritual and socio-emotional status, support and counseling for grieving process, caregiver and family concerns. A joint home visit was conducted on 4/25/2024 at 11:55 a.m., at Patient 1s residence with Visiting Nurse 1. VN stated this is his first time visiting and is just covering for the nurse who regularly visits the patient. On concurrent observation, VN 1 did not perform proper handwashing, did not wear a mask and did not wear gloves during his visit for the patient. During an interview with VN 1 on 4/25/2024 at 12:40 p.m. VN 1 stated that he only has one patient for this agency and is currently working for another agency’s as well. VN 1 stated that he has 5 patients to visit today, and he came from another patient where he performed wound care. VN 1 stated that Patient 1 is his third patient for today. VN 1 stated that it is his personal preference not to wear a mask and stated that the agency’s policy allowed personal preference whether to wear or wear a mask. VN 1 also stated that he uses an alcohol-based hand rub in between home visits and does not want to use the patient’s or family’s soap or use any of their stuff for handwashing. VN 1 stated he encountered a family that told and asked him “Why don’t you bring your own stuff for handwashing?” and stated that he uses an alcohol-based hand rub instead. During an interview with the Director of Patient Care Services (DPCS) on 4/26/2024 at 12:50 p.m., DPCS stated that the visiting nurse should perform handwashing in between succeeding patients and when hands are visibly soiled to prevent the spread of infection. DPCS stated that their Covid-19 Policy was effective since 1/22/2022. There was no other current or updated Covid-19 Policy in the HA’s handbook. A review of the HA’s “Employee Files” on 4/26/2024 indicated there was no copies of Covid-19 staff vaccinations and or medical exemption forms in each employee files. A review of the HA’s Covid-19 Policy date effective 1/22/2022, indicated that the HA will ensure the following processes are in place: Track 100% of staff specified in the COVID-19 VACCINATION POLICY, Document vaccination status in the employee’s health information file. Track and document the COVID-19 vaccination status of all staff who have obtained a booster dose as recommended by CDC. A review of the HA’s policy titled “ Standard Precautions” revised 10/2022 indicated To reduce the risk of exposure to and transmission of infections when caring for patients. Organization personnel will adhere to the following precautions and will instruct patients and family/caregivers in infection control precautions, as appropriate to the patient’s care needs. Hand hygiene will be performed to prevent cross-contamination between the patient and personnel. An alternative to use of an alcohol-based hand rub is to wash hands with an antimicrobial soap and water.”

“Based on interview and record review, the hospice agency failed to provide medical social services (services addressing social and emotional concerns related to the patient’s illness and care and helping the patient access community) to four of six sampled patients, (Patients 2 3, 5 and 6). This failure had the potential that the available services to support the psychosocial needs were not made available and accessible to the patients and family members under the agency’s care. a. During a close record review of Patient 2’s admission record indicated a start of care date of 5/28/23, with a terminal diagnosis of hypertensive heart disease (constellation of changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 2’s Comprehensive Assessment, dated 5/28/23, indicated Patient 2 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 2 had mild dyspnea (shortness of breath) with mild exertion, needs moderate assistance with toileting and transfer, and maximum assistance with bathing and ambulation. During a further review of Patient 2’s clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. b. During a closed record review of Patient 3’s admission record indicated a start of care date of 8/9/2022, with a terminal diagnosis of cardiovascular heart disease (heart conditions that include diseased vessels, structural problems and blood clots). During a review of Patient 3’s Comprehensive Assessment, dated 8/9/2022, indicated Patient 3 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 3 had periods of shortness of breath with moderate exertion, needed moderate assistance with ADLs (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), at moderate risk for falls, had tachycardia (fast heart rate), and had increased respirations (breathing) due to severe pain. During a further review of Patient 3’s clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. c. During a close record review of Patient 5’s admission record indicated a start of care date of 2/13/2022, with a terminal diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During a further review of Patient 5’s clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. d. During a close record review of Patient 6’s admission record indicated a start of care date of 5/28/2023, with a terminal diagnosis of cardiovascular heart disease (heart conditions that include diseased vessels, structural problems and blood clots). During a review of Patient 6’s Comprehensive Assessment, dated 5/28/2023, indicated Patient 6 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on cane for ambulation. Patient 6 had mild dyspnea (shortness of breath) with mild exertion, needs moderate assistance with toileting and transfer, and maximum assistance with bathing and ambulation. During a further review of Patient 6’s clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. During an interview and concurrent record review on 4/26/2024, at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed and acknowledged there was no documented evidence a psychosocial assessment was done and social services rendered for Patients 2,3, 5 and 6. During a review of the agency’s undated policy and procedure titled “Psychosocial Assessment”, indicated a thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. The assessment will be completed and placed in the patients clinical record. A review of the HA’s policy titled “ Initial Assessment” revised May 2022 indicated that the Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment. Nursing and bereavement sections will always be identified. A bereavement assessment of the needs of the patient’s family and other individuals focusing on:1. The nature of the relationship to the patient2. Circumstances surrounding the illness/prognosis3. Behaviors prior to and after the illness/prognosis4. Survivor needs (social, spiritual and cultural) that may impact coping skills5. Potential for pathological grief reactions”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure Spiritual Counseling (designed to address the unique spiritual or religious needs of each patient and their family at the end of life) services was provided to four of six sampled patients (Patients 2, 3, 5 and 6). This deficient practice had the potential to result in Patients 2, 3, 5 and 6 spiritual needs will not be met. a. During a close record review of Patient 2’s admission record indicated a start of care date of 5/28/23, with a terminal diagnosis of hypertensive heart disease (constellation of changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 2’s Comprehensive Assessment, dated 5/28/23, indicated Patient 2 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 2 had mild dyspnea (shortness of breath) with mild exertion, needs moderate assistance with toileting and transfer, and maximum assistance with bathing and ambulation. During a further review of Patient 2’s clinical record indicated there was no documented evidence a spiritual assessment was conducted or any notes from the agencys Chaplain explaining the services being offered by the agency was completed since SOC. b. During a closed record review of Patient 3’s admission record indicated a start of care date of 8/9/2022, with a terminal diagnosis of cardiovascular heart disease (heart conditions that include diseased vessels, structural problems and blood clots). During a review of Patient 3’s Comprehensive Assessment, dated 8/9/2022, indicated Patient 3 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 3 had periods of shortness of breath with moderate exertion, needed moderate assistance with ADLs (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), at moderate risk for falls, had tachycardia (fast heart rate), and had increased respirations (breathing) due to severe pain. During a further review of Patient 3’s clinical record indicated there was no documented evidence a spiritual assessment was conducted or any notes from the agencys Chaplain explaining the services being offered by the agency was completed since SOC. c. During a close record review of Patient 5’s admission record indicated a start of care date of 2/13/2022, with a terminal diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During a further review of Patient 5’s clinical record indicated there was no documented evidence a spiritual assessment was conducted or any notes from the agencys Chaplain explaining the services being offered by the agency was completed since SOC. d. During a close record review of Patient 6’s admission record indicated a start of care date of 5/28/2023, with a terminal diagnosis of cardiovascular heart disease (heart conditions that include diseased vessels, structural problems and blood clots). During a review of Patient 6’s Comprehensive Assessment, dated 5/28/2023, indicated Patient 6 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on cane for ambulation. Patient 6 had mild dyspnea (shortness of breath) with mild exertion, needs moderate assistance with toileting and transfer, and maximum assistance with bathing and ambulation. During a further review of Patient 6’s clinical record indicated there was no documented evidence a spiritual assessment was conducted or any notes from the agencys Chaplain explaining the services being offered by the agency was completed since SOC. During an interview and concurrent record review on 4/26/2024, at 1:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed and acknowledged there was no documented evidence a spiritual counseling services were rendered for Patients 2, 3, 5 and 6. During a review of the agency’s undated policy and procedure titled “Spiritual Assessment”, indicated a spiritual assessment will be completed for each patient/family by the Chaplain. The assessment will include, but not be limited to, evaluation of the following: 1. Coping with and adjusting to the patients terminal illness 2. Assessing bereavement needs 3. Religious and/or spiritual reactions to terminal illness”

“Based on observation, interview and record review, the hospice agency failed to ensure volunteer service program was maintained and was offered /provided to the patients for 1 of 6 sample patients (Patient 1) This deficient practice prevented the patients from receiving benefit from the volunteer program. 1. A review of Patient 1’s “Patient Referral Intake” indicated, an start of care (SOC) date of 2/14/2024, with a diagnosis that included heart disease with heart failure (a condition where there is thickening of the walls of the heart due to increased blood pressure) During a review of Patient 1’s Plan of Care (POC), included an order for Skilled Nursing (SN) to visit once a week plus 2 visits as needed. Medical Social Worker (MSW) and Chaplain once a month, hospice aide refused and for comfort measures only. Hospice to monitor for alteration in cardiovascular status, alteration in comfort, medication education, home safety, spiritual and socio-emotional status, support and counseling for grieving process, caregiver and family concerns. During the joint home visit conducted on 4/25/2024 at 11:55 a.m., at Patient 1s residence with Visiting Nurse 1. When asked if she was offered by the hospice agency other services like volunteers, social worker and chaplain for bereavement. Caregiver stated that she does not remember speaking to a volunteer from the agency nor was it explained to her. During the joint interview of the Administrator and the Director of Patient Care Services on 4/26/2024 at 2:00 p.m., both looked in each others eyes and stated they have a volunteer program but could not provide any information how they utilize their volunteer services. A review of the agency’s policy of “Volunteer Services” indicated the hospice will provide volunteer services under the direction of a volunteer coordinator and with the assistance of trained volunteers.”

“Based on observation, interview and record review, the administrator as part of the governing body failed to assume full authority and responsibility for the management and operation of the hospice agency. This deficient practice had the potential to result in not meeting the hospice patients care needs. An unannounced visit was conducted on 4/24/2024 to 4/26/2024 at 10:30 a.m., at the hospice agency’s current location at 7136 Haskell Ave. Suite 309, Van Nuys CA. Observed that the office was closed and had a note in front of the door that indicated the agency was closed today to observe the Armenian Genocide. There was also instruction to call the on-call staff on 818-855-1002. Called the stated number and left a voice message. Received a return call at 10:50 a.m., and the Administrator stated that she will arrive in 10 minutes. At 11 a.m., the Administrator of the hospice agency arrived and opened the door. Upon entry, at the reception/office area was another room leading to lounge/conference where the printer was located beside a snack bar in the middle part of the suite. There was two rooms adjacent to the office rooms. Inside one of the rooms were multiple boxes containing patient files from 2015. On concurrent interview with the Administrator, stated that she sold one of her agencies and just moved from her previous location about two weeks ago to this current address. Stated that she had filed an agency change in location and that she had communication back and forth for her application. Administrator stated that she does not have a designee and the current agency Director of Patient Care Services (DPCS) was out of town today but will be able to come tomorrow. During the course of the validation survey from 4/24/2024 to 4/26/2024, observed that there was no chaplain, no social worker, no volunteer coordinator that was present in the office to help with the validation survey but the DPCS and the Administrator. A review of the HA’s document titled “ Executive Director/Administrator” indicated The Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. Executive Job Functions/Responsibilities: 1. Operational planning and budgeting.2. Ensuring organizational compliance with legal, regulatory and accreditation requirements.3. Monitoring business operations to insure financial stability. 4. Evaluating hospice services and personnel using measurable outcomes and objectives.5. Conflict and complaint management and resolution.6. Establishing and maintaining effective, open channels of communication including integration or technology, as applicable. Fosters a no-blame culture that encourages reporting of safety and quality of services issues.7. Ensuring hospice personnel stay current with clinical information and practices.8. Ensuring adequate and appropriate staffing.9. Staff development including orientation, in-service, continuing education, competency testing and quality assessment performance improvement.10. Ensuring that interdisciplinary care is provided.11. Ensuring supportive services are available to personnel. 12. Ensuring coordination with other departments, services and senior management, as appropriate.13. Ensuring staff and organization stay current on local and national hospice issues and trends. 14. Ensuring that appropriate service policies and procedures are developed and implemented to accomplish identified outcomes.15. Directing staff in performance of their duties including admission, discharge, transfer, revocation, and provision of service to patients.16. Ensuring appropriate staff supervision during an service hours.17. Monitoring service utilization to ensure delivery of comprehensive care.18. Ensuring services provided by other agencies are authorized by hospice.19. Monitoring operational progress toward accomplishing operational and strategic goals.20. Ensuring appropriate data collection and regular, complete reports are received by the Governing Body.21. Ensuring adequate space, equipment and supplies are available.22. Ensuring actionable objectives are derived from evaluation of hospice services and personnel.23. Ensuring that structure and systems promote interdisciplinary care24. Ensuring collaboration with agencies and vendors for effective management of services.25. Ensuring standards of ethical business and clinical practice are maintained.”

“Based on observation, interview and record review, the hospice agency (HA) failed to assess the skills and competence of all individuals furnishing care, including volunteers as necessary, provide in-service training and education programs where required. This deficient practice has the potential for the staffs’ lack of the current knowledge in providing care and services to hospice patients. A review of the HAs personnel files on 4/26/2024 indicated there was no other documented evidence in all employee files reviewed of performance evaluations. On 4/26/2024 at 1 p.m., during an interview with the Director of Patient Care Services (DPCS) stated that she was present in the office only twice a week because they only have one patient, and she had other agencies that she managed under the same position. On 4/26/2024 at 2 p.m., during an interview with the Administrator stated that she acts as “Human Resource” also and was assigned to hire staff. A review of the HAs policy titled “; Job description: Registered Nurse” indicated the Registered Nurse assumes responsibility for personnel growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and In-service classes. A review of the HAs policy titled “;Administrator” indicated The Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy.”

“Based on interview and record review the hospice agency (HA) failed to ensure clinical records were authenticated by the author for four of 6 sampled patients (Patients 1, 2, 5 and 6). This failure had the potential to result in an unauthorized and inaccurate patient information or assessment entered in the patients clinical record that could affect the patients quality of care and well-being. 1. A review of Patient 1’s “Patient Referral Intake” indicated, an start of care (SOC) date of 2/14/2024, with a diagnosis that included heart disease with heart failure (a condition where there is thickening of the walls of the heart due to increased blood pressure) “;IDT meeting 2/24/2024...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care only the Registered Nurse and the Hospice Physician signed. The Spiritual Counselor, Social Worker , Volunteer Coordinator and other staff involved in the plan of care did not attend the meeting. “;IDT meeting 2/23/2024...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care only the Registered Nurse and the Hospice Physician signed. The Spiritual Counselor, Social Worker , Volunteer Coordinator and other staff involved in the plan of care did not attend the meeting. “;IDT meeting 3/4/2024...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care only the Registered Nurse and the Hospice Physician signed. The Spiritual Counselor, Social Worker , Volunteer Coordinator and other staff involved in the plan of care did not attend the meeting. “;IDT meeting 3/18/2024...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care only the Registered Nurse and the Hospice Physician signed. The Spiritual Counselor, Social Worker , Volunteer Coordinator and other staff involved in the plan of care did not attend the meeting. “;IDT meeting 4/1/2024...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care only the Social Worker, Registered Nurse and the Hospice Physician signed. The Spiritual Counselor, Social Worker , Volunteer Coordinator and other staff involved in the plan of care did not attend the meeting. “;IDT meeting 4/15/2024...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care only the Registered Nurse and the Hospice Physician signed. The Spiritual Counselor, Social Worker , Volunteer Coordinator and other staff involved in the plan of care did not attend the meeting. During a record review of Patient 1’s IDT forms noted that there was an IDT form that was dated 4/29/2024. On concurrent interview with the Director of Patient Care Services (DPCS) on 4/25/2024 at 12:30 p.m., when asked how often the conduct their IDT meetings, DPCS stated every other week. DPCS also stated that the Administrator, Medical Director, Social worker, Volunteer coordinator, Chaplain and skilled nursing are members of the IDT. When asked when is their next scheduled IDT meeting, The DPCS stated “ It was supposed to be today but DPH is here so we will move it after your exit. When asked why is there a form that was dated and signed in advance by the Hospice Physician and the Registered Nurse for 4/29/2024 for Patient 1 IDT meeting, The DPCS stated it was put in the chart in error. 2. A review of Patient 2’s “Patient Referral Intake” indicated, an SOC date of 5/28/2023, with a diagnosis that included diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy). A phone call attempt was made to Patient 6 on 4/26/2024 at 9:08 a.m., at phone number 805-747-3103 and a voice prompt stated “ this phone number cannot be completed as dialed, please check the number and dial again”. A re-check was made on the patient referral intake form and redialed the same number and still received the same voice prompt. A phone call attempt was made to Patient 6’s emergency contact at 626-537-1984 and its a none working number. 3. A review of Patient 5’s “Patient Referral Intake” indicated, an SOC date of 2/13/2022, with a diagnosis that included end stage chronic obstructive pulmonary disease (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing). A phone call attempt was made to Patient 5 on 4/26/2024 at 10:00a.m., at phone number 213-810-8832 and a male person answered the phone and stated “I am not affiliated with this person and you dialed the wrong number.” 4. A review of Patient 6’s “Patient Referral Intake” indicated, an SOC date of 5/28/2023, with a diagnosis that included hypertensive heart disease with heart failure. A phone call attempt was made to Patient 5 on 4/26/2024 at 9:08 a.m., at phone number 805-747-3103 and a voice prompt stated “ this phone number cannot be completed as dialed, please check the number and dial again”. A re-check was made on the patient referral intake form and redialed the same number and still received the same voice prompt. A phone call attempt was made to Patient’ 2’s emergency contact at 626-537-1984 and its a none working number. During a joint interview with the Administrator and the Director of Patient Care Services on 4/26/2024 at 2:00 p.m., both stated they do not what happened to the numbers. Admin stated when they were our patients we were able to speak to them. A review of facilitys policy and procedure titled, “;Clinical/Service Data Collection”, indicated “;A clinical/service record will be initiated and maintained for each patient... and will include at a minimum: Pertinent medical history... current patient status and progress toward goals... Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided... Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include: the date the service was provided... signature of clinician/technician and his/her credentials.””

“Based on interview and record review, the HA failed to follow their policy on documentation of discharge summary and discharge assessment for one of 6 sampled patients (Patient 4) after discharge from the HA. This failure resulted in incomplete documentation and communication of the patient’s plan of care on record. 1. A review of Patient 4’s document titled “Referral Intake” indicated, a start of care (SOC) date of 5/27/2024, with diagnosis of end stage heart disease (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest. Symptoms may include shortness of breath, fatigue, and heart arrhythmias) A review of the HA’s document titled “ Certification of Terminal Illness” dated 5/27/2023 for the benefit period of 5/27/2023 to 8/25/2023 indicated Patient is admitted for End Stage Cardiac Disease with co-morbidities of the following: Hypertension, Dementia, Osteoporosis, Osteoarthritis, Personal History of Breast Neoplasm. Patient is weak and progressively declining in the past 2 weeks. Patient relies on and assisted by patient/caregiver (PCG) with all his personal care and other activities of daily living 6/6. Patient is incontinent with urine. Patient has history of neoplasm (cancer) on the Breast. Patient has KPS (Karnofsky Performance Status- A standard way of measuring the ability of cancer patients to perform ordinary task) and PPS(Palliative Performance Scale- used to measure functional performance of and to predict survival) and a score of 60% FAST (Functional Assessment Staging Scale-a practical, functional assessment tool used to define and grade all forms of dementia) of 6D (moderately severe). During a review of Patient 4’s medical record showed a communication note dated 6/21/2023 signed and dated by the HA’s hospice physician and signed by the registered nurse as a verbal order indicating “ Patient’s family refused further visits. No SN (skilled nurse) visit made. All discipline had been notified.” There was no discharge summery and no discharge orders in the clinical record. A phone call attempt was made to Patient 4’s phone number on 4/26/2024 at 9:15 a.m., and spoke to Patient 4’s daughter/caregiver. Caregiver stated that her mom’s primary care physician was not the stated physician on record. Caregiver stated that her mom has Alzheimer’s/dementia (A progressive disease that destroys memory and other important mental functions) and liver cirrhosis (severe scarring of the liver). Caregiver stated that she remembers that her mom was discharged from the agency and was told by the nurse that her mom was “Limited at what she can have”. When asked what that meant or was it further explained to her, caregiver stated that the nurse who called did not explain. Caregiver also stated that she wanted to be transferred to another hospice agency to continue her care.” Caregiver stated she did not refuse hospice services from the agency. Caregiver stated the nurse told her that she is limited with what she can have.” During a joint interview with the Administrator (Admin) and Director of Patient Care Services (DPCSD) on 4/26/2024 at 2 p.m., both could not answer the reason why this patient was discharged. A review of the HA’s titled “ Interdisciplinary Group Meeting” dated April 2018, indicated Patient being discharged from hospice will be reviewed to ensure appropriateness of ongoing care. patient requesting transfer to another hospice or revocation of the hospice benefit will be reviewed to determine any assistance he/she may need to complete these processes. A review of the HA’s document titled “Contents of the Clinical Record”, indicated A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patients, describe the patient problems /needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The following information will be available in the clinical record, as applicable to care and services provided: Discharge summary and other summary reports sent to the physician, as required by law, regulation, and organization policy. Any instructions given to the patient, if discharged. Documentation of the assessment data collected, actions and interventions performed, and patients response to the care provided.”