Premier at Home Hospice & Palliative Care, LLC

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address, arrangements with facilities and other providers to receive patients to maintain the continuity of care to patients. This standard was not met as evidenced by document review and interview. A review of the agency’s emergency preparedness binder and plan revealed no documented evidence that the agency had made arrangements with another facility or provider to receive patients in the event of an emergency. During an interview, the Executive Director /Director of Nursing stated he did not realize that he needed this and would work on how best to approach this. A review of the Emergency Preparedness Binder on 01/04/2024 revealed no documentation of relation with another hospice to provide care for patients in the event of an emergency in which staff is not sufficient for the need. Interview with the Executive Director/Administrator who stated that he did not realize that he needed this. He stated that he would think about how best to approach this.”

“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 document review, clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. Agency policy 4.18 Comprehensive Assessment stated in part, “The comprehensive assessment of the patient is completed by a designated member of the IDG, in consultation with the patient’s attending physician no later than five (5) calendar days after the patient elects the hospice benefit.” Clinical Record 2: The patient elected the hospice benefit on 10/26/2023 with a terminal diagnosis of senile degeneration of brain. The initial plan of care dated 10/26/2023 included an order for Medical Social Worker (MSW) services beginning date 10/26/2023. Clinical record review revealed the initial MSW visit was documented on 11/15/2022, 20 days after the patient elected the hospice benefit and 15 days outstanding. There was no documentation of missed visit(s) or communication from the MSW that any attempt was made to complete the psychosocial assessment before day 20. Clinical Record 3: The patient elected the hospice benefit on 11/21/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The initial plan of care dated 11/21/2023 included an order for Medical Social Worker services beginning date 11/21/2023. Clinical record review revealed the initial MSW visit was documented on 11/30/2022, 9 days after the patient elected the hospice benefit and 4 days outstanding. There was no documentation of missed visit(s) or communication from the MSW that any attempt was made to complete the psychosocial assessment before day 20. During an interviewed on 01/03/2023, Executive Director /Director of Nursing stated he did not see documentation of a phone contract before the visit dates.”

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by document review, clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure the documented assessment of the patient’s pain includes the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. Agency policy 4.42 Pain and Symptom Management stated in part, “If a patient’s pain score is above their acceptable rating or the patient states that their pain level is not acceptable, the pain will be reassessed within twenty-four (24) hours to ensure it has come down to an acceptable level.” Clinical Record 2: The patient elected the hospice benefit on 10/26/2023 with a terminal diagnosis of senile degeneration of brain. The initial plan of care dated 10/26/2023 included an intervention that the patient’s pain was to be controlled as tolerable. The initial comprehensive assessment dated 10/26/2023 included documentation that the patient’s pain level was 6 on a 0/10 scale and the patient was using Tylenol for pain control. The assessment did not include documentation if a level 6 pain was acceptable to the patient, but did document education provided about the timing of medication to keep pain controlled. The next nursing assessment visit was documented on 11/09/2023. The clinical record did not include documentation or communication with the patient to follow-up with the increased pain level reported at the 10/26/2023 nursing visit or to assess the effectiveness of the Tylenol at reducing the patient’s pain. Agency staff did not follow the agency’s policy to reassess pain within 24 hours to ensure it has come to an acceptable level for the patient. During an interview and review of records, the Executive Director /Director of Nursing agreed that staff should have follow-up sooner to reassess the patient’s pain.”

“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 1 of 5 (20%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse prepared a patient specific aide plan of care assignment with clear and specific instructions for the aide. Clinical Record 1: The aide care plan of care assignment developed by the RN and dated 12/13/2023 assigned the aide the tasks of “Partial bed bath (patient assist) if shower refused. A shower stand-by assist.” The aide plan of care did not include specific instructions for the aide with guidelines for when to perform each type of bath. During an interview and record review, the Executive Director /Director of Nursing agreed the aide care plan did not provide clear instruction.”

“It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice, nursing services, medical social services, physician services, hospice aide, volunteer, and homemaker services, physical therapy, occupational therapy, and speech-language pathology services, short-term inpatient care, counseling services, including spiritual counseling, bereavement counseling, and dietary counseling. This standard was not met as evidenced by document review, observation, and interview. A joint contract review with the Executive Director /Director of Nursing (DON) revealed the agency did not have a contract for therapy services, including physical therapy, occupational therapy and speech-language pathology. During a joint review of agency contracts, the DON revealed the agency did not have a signed contract for therapy services. The DON stated that for patients that reside in a Skilled Nursing Facility (SNF), the agency had an agreement with the SNF to provide therapy services if needed but it was not documented in a contract. The DON stated the agency did not have a contract to provide therapy services for patients that reside in their own home. The DON stated the one patient that lives in their own home did not require therapy services. Review of the active census revealed that currently the agency has one patient that resides in their own home and all other patients are residents of SNFs. A home visit observation (Clinical Record 1/Home Visit 1) was completed with the patient that resided at home and therapy needs were not identified for the patient. The DON acknowledged the need to obtain a therapy contract for all patients of the agency. A joint contract review with the administrator revealed no signed contract for therapy services.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, the most recent hospice plan of care. This standard was not met as evidenced by document review, observation, and interview. In 2 of 2 (100%) home visit observations with patients that reside at a skilled nursing facility [SNF], the agency did not ensure that the facility was provided with the most recent plan of care. Agency policy 4.32 stated in part, “The hospice will provide the following information to the facility: Hospice plan of care, election forms, advance directives, and certifications.” Home Visit 2: During the home visit observation with the Registered Nurse, review of the hospice binder at the SNF revealed no documented evidence that the initial hospice plan of care and the updated plans of care were in the hospice binder and provided to the SNF. Home Visit 3: During the home visit observation with the Registered Nurse, review of the hospice binder at the SNF revealed no documented evidence that the initial hospice plan of care and the updated plans of care were in the hospice binder and provided to the SNF. During an interview on 01/04/2024, the Executive Director /Director of Nursing stated that he did not realize all the forms needed to be in the binder.”

“It is required that the designated IDG [interdisciplinary group] member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, the hospice election form and any advanced directives. This standard was not met as evidenced by document review, observation, and interview. In 2 of 2 (100%) home visit observations with patients that reside at a skilled nursing facility [SNF], the agency did not ensure that the facility was provided with the hospice election form. Agency policy 4.32 stated in part, “The hospice will provide the following information to the facility: Hospice plan of care, election forms, advance directives, and certifications.” Home Visit 2: During the home visit observation with the Registered Nurse, review of the hospice binder at the SNF revealed no documented evidence that the patient’s hospice election of benefit form was in the hospice binder and provided to the SNF. Home Visit 3: During the home visit observation with the Registered Nurse, review of the hospice binder at the SNF revealed no documented evidence that the patient’s hospice election of benefit form was in the hospice binder and provided to the SNF. During an interview on 01/04/2024, the Executive Director /Director of Nursing stated he did not realize the election of benefit form needed to be in the binder.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, physician certification and recertification of the terminal illness. This standard was not met as evidenced by document review, observation, and interview. In 2 of 2 (100%) home visit observations with patients that reside at a skilled nursing facility [SNF], the agency did not ensure that the facility was provided with the physician certification of terminal illness. Agency policy 4.32 stated in part, “The hospice will provide the following information to the facility: Hospice plan of care, election forms, advance directives, and certifications.” Home Visit 2: During the home visit observation with the Registered Nurse, review of the hospice binder at the SNF revealed no documented evidence that the physician certification of terminal illness was in the hospice binder and provided to the SNF. Home Visit 3: During the home visit observation with the Registered Nurse, review of the hospice binder at the SNF revealed no documented evidence that the physician certification of terminal illness was in the hospice binder and provided to the SNF. During an interview on 01/04/2024, the Executive Director /Director of Nursing stated he did not realize the forms needed to be in the binder.”