Comprehensive Comm Hospice of Parker Jewish Inst

“Based on patient record review and interviews with the Hospice Administrator/Director of Patient Services, the Governing Body failed to ensure a written care plan for each patient that specifies the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions (L536). The Governing Body failed to ensure the designation of an interdisciplinary group 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 (L539). The Governing Body failed to designate a registered nurse that is a member of the disciplinary group to provide coordination of care and ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care (L540). The Governing Body failed to ensure all hospice care and services furnished to patients and their families follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needed if any of them so desire (L543). The Governing Body failed to ensure the hospice develops an individualized written care plan for each patient that reflects the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessment (L545). The Governing Body failed to ensure the hospice develops a plan of care detailing interventions to manage pain and symptoms (L546). The Governing Body failed to ensure the hospice develops a plan of care detailing the scope and frequency of services necessary to meet the specific patient and family needs (L547). The Governing Body failed to ensure the hospice develop measurable outcomes anticipated from implementing and coordinating the plan of care (L548). The Governing Body failed to ensure the hospice interdisciplinary group review, revise, and document the individualized plan as frequently as the patients condition requires, but no less frequently than every fifteen (15) calendar days (L552). The Governing Body failed to ensure the care and services provided are in accordance with the plan of care (L555). The Governing Body failed to ensure the hospice provides for and ensures the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement (L557). The cumulative effect of these systemic practices resulted in the hospice’s inability to ensure the provision of quality health care to patients receiving services which has the potential for negative outcomes for the entire patient population and organizational operations.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 to 2024, and interviews with the Hospice Administrator/Director of Patient Services, the Governing Body failed to ensure the development, implementation and maintenance of a hospice-wide data driven Quality Assessment program (L561). The Governing Body failed to show measurable improvement in indicators relating to improved palliative outcomes (L561). The Governing Body failed to ensure that quality indicators, including adverse events defined by the agency, were tracked and analyzed to assess processes of patient care, hospice services and operations (L562). The Governing Body failed to ensure the Quality Assessment and Performance Improvement program collected sufficient quality indicator data that included evaluating all aspects of patient service and activities that may impact patient and family care and all facets of the hospice’s operation (L563). The Governing Body failed to ensure the data collected was used to monitor the effectiveness and safety of services and patient care, was used to identify and prioritize opportunities for improvement (L564). The Governing Body failed to ensure Quality Assessment and Performance Improvement activities focused on high risk and problem prone areas (L566). The Governing Body failed to identify the incidence, prevalence and severity of problems in those areas (L567). The Governing Body failed to ensure the program activities palliative outcomes are the result of the palliative care provided (L568). The Governing Body failed to develop performance improvement activities that were tracked and analyzed to ensure improvements continued (L569). The Governing Body failed to develop performance improvement activities, take actions at performance improvements, and after implementing these actions, measure its success to ensure that improvements are sustained (L570). The Governing Body failed to develop, implement and evaluate performance improvement projects (L571). The Governing Body failed to ensure the performance improvement projects contained documentation based on the needs of the patient population and internal organizational needs (L572). The Governing Body failed to ensure performance improvement projects contained documentation of measurable goals (L573). The Governing Body failed to ensure the hospice-wide Quality Assessment and Performance Improvement efforts addresses priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness (L574). The Governing Body failed to ensure Quality Assessment and Improvement activities were prioritized to address improved quality care and patient safety, that the appropriate interventions were put in place and those interventions evaluated for their effectiveness (L575). The cumulative effect of these systemic practices resulted in the hospice’s inability to ensure the provision of quality health care and self-identify areas in need of improvement which has the potential for negative outcomes for the entire patient population and organizational operations. The Governing body failed to maintain an effective Quality Assessment and Performance Improvement program that reflects the complexity of its services, focuses on indicators related to improve palliative care, and takes actions to demonstrate in hospice performance.”

“Based on clinical record review and staff interviews, the hospice failed to ensure patients have the right to request at any time, in writing, of notification of Hospice Non-Covered items, services and drugs. This was evident in two (2) of fourteen (14) patients clinical records selected for review during the survey (Patient #1, #14). Failure to ensure that patients and families are informed about all the services covered /non-covered under the Hospice benefit has the potential to place patients at risk for unmet needs and negative patient outcomes. The findings are: 1) Patient #1 has a start of care and a benefit election date of 1/9/2024 with diagnoses including Advanced Dementia and Weight Loss as documented on the “Orders/Plan of Care, 3/9/2024- 5/7/2024.” The document titled “ Consent for Election of Medicare/Medicaid Hospice Benefit-form 105-E, revised 9/21”, signed by patient’s legal guardian and Hospice representative on 12/18/2023 and 12/19/2023 did not include notification by Hospice to patient /guardian of their rights to request information and listings of non-covered items, services, drugs the hospice has determined to be unrelated to illness and not covered by hospice. The finding was brought to the attention of the hospice Administrator, Clinical Nurse Manager during interview on 5/7/2024 at 3:30PM. No explanation was provided. 2) Patient # 14 with a start of care date of 11/30/2023 with diagnoses including Cerebral Atherosclerosis, Cancerous Lesion, Right Upper Arm, Weight Loss, and Spinal Stenosis as documented on the “Orders/Plan of Care recertification period of 1/29/2024-3/28/2024.” The document titled “ Consent for Election of Medicare/Medicaid Hospice Benefit-form 105-E, revised 9/21”, signed by patient’s legal guardian and Hospice representative on 11/30/2023 did not include notification by Hospice to patient/guardian of their rights to request information and listings of non-covered items, services, drugs the hospice has determined to be unrelated to illness and not covered by hospice. The finding was brought to the attention of the hospice Administrator, Nurse Manager during interview on 5/7/2024 at 3:30PM. No explanation was provided.”

“Based on record review and staff interview the Hospice failed to ensure that the patient receive information about the scope of services that the hospice will provide and specific limitations on those services. This was evident for one (1) of two ( 2 ) patients discharged from hospice Care ( Patient #13). Failure to ensure that the patient receive information about the scope of services that the hospice will provide and specific limitations on those services has the potential for negative patient outcomes. The findings are: Patient #13 has a start of care date of 8/24/2023 and a discharge date of 11/17/2024. The” Social Work Routine Visit Note” dated 8/31/2023, 9/7/2023, 9/18/2023,9/26/2023, 10/4/2023, 11/3/2023 document:” Anticipated discharge discussed with patient and family: No. Notice of non-coverage not appropriate”. The surveyor reviewed a Notice of Medicare Non-Coverage dated 11/17/2023. The document states :” the effective date of your current Hospice Services will end: 11/17/2023. Social Worker emailed Notice of Medicare non coverage to patients son and phone to confirm receipt and understands the content of the notice and also the appeal process. They also understand that patient can be referred to Hospice again if there is a decline in patients condition”. The” Charts/ Clinical Notes” dated 11/10/2023, at 1:03 PM, document:” This Social Worker called patients son to inform him that patient will be discharged for the Hospice program due to no longer meeting criteria. Patients daughter in law answered his phone, saying her spouse will return shortly and asked the nature of the call, writer informed her about the notice of Medicare Non-Coverage and explaining the appeal process. The daughter in Law stated the family will be appealing this decision. Writer her the form and then called her to ensure the form was received which she confirmed. Writer visited patient at the bedside. Writer explained the purpose of the visit which was to give her the Notice of Medicare Non-Coverage because she does not meet criteria for hospice at this time. She expressed understanding and stated that she will discuss this with her son and that she hopes services can continue. Writer extended empathic listening and offered emotional support to patient. The” Charts/ Clinical Notes” dated 11/10/2023 at 3:15 PM document:” Writer called again, spoke with patients son who confirmed that received and understand Notice of Medicare Non-Coverage, He stated that he is thinking of appealing the decision”. The” Charts/ Clinical Notes” dated 11/10/2023 at 4:06 Patients son called regarding the notice of non-coverage, telling writer he called to appeal and is awaiting the decision. Writer offered support”. The” Case Conference Report” dated 11/24/2023 document:” Patient was discharged from services 11/17/2023 due to not meeting Hospice criteria”. There is no documented evidence the patient exercised her rights to the appeal process by not being informed of the scope of services and the specific limitations of those services. On 5/9/2024 at 3:45 PM, the Administrator was interviewed and did not provide an explanation of the findings.”

“Based on record review and staff interview, the Hospice failed to ensure completion and documentation of 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. This was evident for eight (8) of fourteen (14) clinical records reviewed (Patients #2, #3, #4, #5, #6, #7, #9 and #12). Failure to ensure an initial bereavement assessment is completed has the potential for negative patient outcomes. The findings are: 8) Patient #12 has a start of care date of 11/2/2023 and an expiration date of 11/27/ 2023 with diagnoses that include Malignant neoplasm of Upper Lobe, Left Bronchus or Lung, Secondary Malignant Neoplasm of Bone, Secondary Neoplasm of Liver and Intrahepatic Bile Duct as documented on the “;Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 12/1/2023. The “;Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 12/1/2023 documents:” Medical Social Worker: Provide reassurance to patient/ family throughout dying process, encourage ventilation of feelings/ fears, provide immediate emotional support and reassurance to patient/ family. Spiritual Care: Provide spiritual counseling/ supportive presence”. There is no documented evidence of an initial bereavement assessment in the clinical record. On 5/9/2024, at 3:40 PM, the Administrator was interviewed and did not provide an explanation for the findings. 5) Patient # 6 has a Start Of Care date of 3/12/2024 with diagnosis of “Thyrotoxicosis with diffuse goiter without Thyrotoxic crisis or storm, Hypothyroidism unspecified, Unspecified Dementia-unspecified severity without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 1 to 2 times per month for 4 months”. The “Social Work Initial Visit” note dated “03-14-2024” lacks documented evidence of an initial bereavement assessment. The clinical record lacks documented evidence of an initial bereavement risk assessment focused on the needs of the bereaved. 6) Patient # 7 has a Start Of Care date of 1/31/2024 with diagnosis of “Malignant Neoplasm of Bladder-Unspecified” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “01-31-24 to 04-29-24”. The Hospice “Physician’s Orders/Plan of Care” dated “01-31-24 to 04-29-24” documents orders for “SN (Skilled Nurse) 1 time a week for 14 weeks, MSS (Medical Social Services) 1 time a month for 1 month”. The “Social Work Initial Visit” note dated “02-05-2024” lacks documented evidence of an initial bereavement assessment. The clinical record lacks documented evidence of an initial bereavement risk assessment focused on the needs of the bereaved. 7) Patient # 9 has Start Of Care date of 1/4/2024 with a diagnosis of “Alzheimer’s Disease-unspecified” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “01-04-24 to 03-03-24”. The Hospice “Physician’s Orders/Plan of Care” dated “01-04-24 to 03-03-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks, MSS (Medical Social Services) 1 to 3 times per month for 3 months, SC (Spiritual Counselor) 1 to 3 times per month for 3 months”. The “Social Work Initial Visit” note dated “01-12-2024” lacks documented evidence of an initial bereavement assessment. The clinical record lacks documented evidence of an initial bereavement risk assessment focused on the needs of the bereaved. On 5/9/2024 at 3:50pm findings and interview was conducted with the Administrator, no additional information received. 2) Patient #3 has a start of care date of 03/05/2024 with diagnoses of Alzheimers Disease Late onset, Dementia, Parkinsonism, Unspecified Atrial Fibrillation, Repeated Falls, Orthostatic Hypotension, Hyperlipidemia, Fracture of Ribs, left side, Long-term use of anti-coagulant, and Encounter for Palliative Care as documented on the “;Physicians Orders/Plan of Care” from 03/05/2024 to 06/02/2024. The “;Physicians Orders/Plan of Care” from 03/05/2024 to 06/02/2024 documents an order for Skilled Nurse 1-2x week x 13 weeks (one to two visits a week for thirteen weeks), Medical Social Services 1- 2x month for 3 months (one to four times a month for three months). Medical Social Services to “;provide reassurance to patient/ family throughout dying process, encourage ventilation of feelings/ fears, provide immediate emotional support and reassurance to patient/ family, provide spiritual counseling/ supportive presence”. The” Initial Visit” assessment dated 03/05/2024, performed of the Skilled Nurse/Registered Nurse lack documented evidence of an initial bereavement assessment of the needs of the patient/family that may impact their ability to cope with the terminal illness and death. The “;Social Work Initial Visit” assessment dated 03/12/2024 lack documented evidence of an initial bereavement assessment of the needs of the patient/family that may impact their ability to cope with the terminal illness and death. The clinical record lacks documented evidence of an initial bereavement assessment was conducted from03/05/2024 to 05/10/2024 (survey date). The survey findings and interview were conducted on 05/08/2024 at 12:04 PM with the Administrator, Patient Service Manager and Senior Vice President. No explanation was provided. 3) Patient #4 has a start of care date of 12/05/2023 with diagnoses of Heart failure, COVID -19, Alzheimers Disease, Unspecified Dementia, Hypertensive Heart Disease, Acute Chronic Diastolic Heart Failure, Essential Hypertension and Muscle Weakness as documented on the “;Physicians Orders/Plan of Care “;from 12/05/2023 to 03/03/2024. The “;Physicians Orders/Plan of Care “;from 12/05/2023 to 03/03/2024 documents orders for “;Skilled Nurse 1-2x week x 12 weeks (one to two visits a week for twelve weeks), Medical Social Services 1- 2x month for 3 months (one to four times a month for three months), Aide (Hospice Service Aide) 3 – 5 x week x 12 weeks (three to five times a week for twelve weeks), Spiritual Counseling 1-2 x month x 3 months (one to two times a month for three months)”. The” Initial Visit” assessment dated 12/05/2023, performed of the Skilled Nurse/Registered Nurse lack documented evidence of an initial bereavement assessment of the needs of the patient/family that may impact their ability to cope with the terminal illness and death. The “;Social Work Initial Visit” assessment dated 12/07/2023 lack documented evidence of an initial bereavement assessment of the needs of the patient/family that may impact their ability to cope with the terminal illness and death. The clinical record lacks documented evidence of an initial bereavement assessment was conducted from 12/05/2023 to 05/10/2024 (survey date). The survey findings and interview were conducted on 05/08/2024 at 12:09 PM with the Administrator, Patient Service Manager and Senior Vice President. No explanation was provided. 4) Patient #5 has a start of care date of Cerebral Atherosclerosis as documented on the “;Physicians Orders/Plan of Care from 04/03/2024 to 07/01/2024. The “;Physicians Orders/Plan of Care” from 04/03/2024 to 07/01/2024 documents orders for “;Skilled Nurse 1-2x week x 13 weeks (one to two visits a week for thirteen weeks), Medical Social Services 1- 2x month for 3 months (one to four times a month for three months), Aide (Hospice Service Aide) 3 – 5 x week x 13 weeks (three to five times a week for thirteen weeks), Spiritual Counseling 1-2 x month x 3 months (one to two times a month for three months)”. The” Initial Visit” assessment dated 04/03/24, performed of the Skilled Nurse/Registered Nurse lack documented evidence of an initial bereavement assessment of the needs of the patient/family that may impact their ability to cope with the terminal illness and death. The “;Social Work Initial Visit” assessment dated 04/05/24 lack documented evidence of an initial bereavement assessment of the needs of the patient/family that may impact their ability to cope with the terminal illness and death. The clinical record lacks documented evidence of an initial bereavement assessment was conducted from 04/03/2024 to 05/10/2024 (survey date). The survey findings and interview were conducted on 05/09/2024 at 04:03 PM with the Administrator, Patient Service Manager and Senior Vice President. No explanation was provided. 1) Patient # 2 has a Start of Care date of 11/10/2023 with diagnosis of Malignant Neoplasm of female Breast with Metastasis to Bone, Schizophrenia, Depression, Type 2 Diabetes, Hyperlipidemia as documented on the Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24”. The Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 3 times per month for 4 months and Aide 1 to 3 times per week for 1 week, 1 to 5 time per week for 12 weeks”. The “Social Work Initial Visit” note dated “11/14/2023” lacks documented evidence of an initial bereavement assessment. The clinical record lacks documented evidence of an initial bereavement risk assessment focused on the needs of the bereaved. On 5/9/2024 at 3:30pm findings reviewed with the Administrator and Patient Service Manager; no addition information provided.”

“Based on record review and interviews, the Hospice interdisciplinary group (IDG) failed to update comprehensive assessments to ensure that the hospice interdisciplinary group has the most recent accurate information about the patient/family as frequently as the condition of the patient requires in order to make accurate care planning decisions. This was evident in eight (8) of fourteen (14) clinical records reviewed (Patients #2, #6, #7, #9, #10, #11, #12, and #13). Failure to ensure the Hospice interdisciplinary group (IDG) update comprehensive assessments as frequently as the condition of the patient requires has the potential for negative patient outcomes. The findings are: 6) Patient #11 has a start of care date of 7/18/2023 and an expiration date of 8/6/2023 with diagnoses that include Cerebral Atherosclerosis, Personal History of Transient Ischemic Attack and Cerebral Infarction without residual deficits, Gastrointestinal Hemorrhage as documented on the “;Physicians Orders / Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023. The “; Physicians Orders / Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023 documents:” Skilled Nurse assess /instruct patient family in disease process/ progression and management of symptoms. Medical Social Worker: Encourage ventilation of feelings/ fears, provide immediate, emotional support and reassurance to patient/ family”. There is no documented evidence of an update of a Comprehensive assessment by the Interdisciplinary Group every 15 days or more frequently as needed. 7) Patient #12 has a start of care date of 11/2/2023 and an expiration date of 11/27/2023 with diagnoses that include Malignant neoplasm of Upper Lobe, Left Bronchus or Lung, Secondary Malignant Neoplasm of Bone, Secondary Neoplasm of Liver and Intrahepatic Bile Duct as documented on the “;Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 12/1/2023. The “;Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 12/1/2023 documents:” Skilled Nurse assess /instruct patient family in disease process/ progression and management of symptoms. Medical Social Worker: Provide reassurance to patient/ family throughout dying process, encourage ventilation of feelings/ fears, provide immediate emotional support and reassurance to patient/ family. Spiritual Care: Provide spiritual counseling/ supportive presence”. There is no documented evidence of an update of a Comprehensive assessment by the Interdisciplinary Group every 15 days or more frequently as needed. 8) Patient #13 has a start of care date of 8/24/2023 and a discharge date of 11/17/2023 with diagnoses that include Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Cardiogenic Shock, Pulmonary Hypertension as documented on the” Physicians Orders / Plan of Care” for the Certification Period of 8/24/2023 to 11/21/2023. Physicians Orders / Plan of Care” for the Certification Period of 8/24/2023 to 11/21/2023 documents:” Skilled Nurse assess /instruct patient family in disease process/ progression and management of symptoms. Medical Social Worker: Encourage ventilation of feelings/ fears, provide immediate, emotional support and reassurance to patient/ family. Spiritual Care: Provide spiritual counseling supportive presence. The “ Case Conference Summary Report” document Interdisciplinary Group meetings on 8/31/2023, and 11/24/2023. There is no documented evidence of an update of the comprehensive assessment of the patient by the Interdisciplinary Group every 15 days or more frequently as needed. On 5/9/2023 at 3:30 PM, the Administrator was interviewed and did not provide an explanation for the findings. 3) Patient # 6 has a Start Of Care date of 3/12/2024 with diagnosis of “Thyrotoxicosis with diffuse goiter without Thyrotoxic crisis or storm, Hypothyroidism unspecified, Unspecified Dementia-unspecified severity without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24”. The Hospice “IDG (Interdisciplinary Group) Week of 3/18/24” and “Week of 4/29/24”, “Case Conference Summary Report” noted in the clinical record. The clinical record lacks documented evidence of updates every 15 days or more frequently during the Certification Period. The clinical record lacks documented evidence of an Interdisciplinary Group/Attending Physician comprehensive assessment. There is no documented evidence the Interdisciplinary Group is updated to meet the Palliative needs of the Hospice patient. The Hospice failed to meet the Hospice patient Palliative needs. 4) Patient # 7 has a Start Of Care date of 1/31/2024 with diagnosis of “Malignant Neoplasm of Bladder-Unspecified” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “01-31-24 to 04-29-24”. The Hospice “IDG (Interdisciplinary Group) Week of 4/22/2024, “Case Conference Summary Report” noted in the clinical record. The clinical record lack documented evidence of updates every 15 days or more frequently during the current Certification Period. The clinical record lacks documented evidence of an Interdisciplinary Group/Attending Physician comprehensive assessment for the current Certification Period. There is no documented evidence the Interdisciplinary Group is updated to meet the Palliative needs of the Hospice patient. The Hospice failed to meet the Hospice patient current Palliative needs. 5) Patient # 9 has Start Of Care date of 1/4/2024 with a diagnosis of “Alzheimer’s Disease-unspecified” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “01-04-24 to 03-03-24”. The clinical record lacks documented evidence of an Interdisciplinary Group/Attending Physician comprehensive assessment for the current Certification Period. There is no documented evidence the Interdisciplinary Group is updated to meet the Palliative needs of the Hospice patient. The Hospice failed to meet the Hospice patient current Palliative needs. On 5/9/2024 at 3:50pm findings and interview was conducted with the Administrator, no additional information received. 1) Patient # 2 has a Start of Care date of 11/10/2023 with diagnosis of Malignant Neoplasm of female Breast with Metastasis to Bone, Schizophrenia, Depression, Type 2 Diabetes, Hyperlipidemia as documented on the Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24”. The Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 3 times per month for 4 months and Aide 1 to 3 times per week for 1 week, 1 to 5 time per week for 12 weeks”. The record document an Interdisciplinary Group meeting on 11/16/2023 and 04/25/2024. There is no documented evidence of an update of the comprehensive assessment of the patient by the Interdisciplinary Group every 15 days or more frequently as needed. 2) Patient # 10 has a Start of Care date of 09/05/2023 with diagnosis of Cerebral Atherosclerosis, Hypertension, Chronic Kidney Disease, Hyperlipemia and Unspecified Gout as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks,1 times per week for 1 week, MSS (Medical Social Services) 1 to 2 times per month for 3 months, SC (Spiritual Counselor) 1 to 2 times per month for 3 months and Aide 1 to 2 times per week for 1 week, 1 to 5 time per week for 8 weeks and 1 to 2 times per week times one week”. The record document an Interdisciplinary Group meeting on 01/11/2024 and 04/25/2024. There is no documented evidence of an update of the comprehensive assessment of the patient by the Interdisciplinary Group every 15 days or more frequently as needed. On 5/9/2024 at 3:30pm findings reviewed with the Administrator and Patient Service Manager; no addition information provided.”

“Based on record review and staff interview, the hospice failed to designate an interdisciplinary group or groups 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. This was evident for two (2) of fourteen (14) patient records reviewed (Patients #2 and #10). Failure to designate an interdisciplinary group or groups 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 placed patients at risk for negative patient outcomes. The findings are: 1) Patient # 2 has a Start of Care date of 11/10/2023 with diagnosis of Malignant Neoplasm of female Breast with Metastasis to Bone, Schizophrenia, Depression, Type 2 Diabetes, Hyperlipidemia as documented on the Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24”. The Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 3 times per month for 4 months and Aide 1 to 3 times per week for 1 week, 1 to 5 time per week for 12 weeks”. The record documents an Interdisciplinary Group meeting on 11/16/2023 listed “;Participants electronic signatures; a Register Nurse, two Administrator Scribes (to document meeting) and Spiritual Counselor”. The record documents an Interdisciplinary Group meeting on 04/25/2024 listed participants electronic signatures: a Registered Nurse, an Administrator Scribe and two Spiritual Counselors. There is no documented evidence of a Social Worker participating in meetings and no electronic signature documented. There is no documented evidence of a Physician participating in meetings and no electronic signature documented. 2) Patient # 10 has a Start of Care date of 09/05/2023 with diagnosis of Cerebral Atherosclerosis, Hypertension, Chronic Kidney Disease, Hyperlipemia and Unspecified Gout as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks,1 times per week for 1 week, MSS (Medical Social Services) 1 to 2 times per month for 3 months, SC (Spiritual Counselor) 1 to 2 times per month for 3 months and Aide 1 to 2 times per week for 1 week, 1 to 5 time per week for 8 weeks and 1 to 2 times per week times one week”. The record documents an Interdisciplinary Group meeting on 01/11/2024 listed “;Participants electronic signatures; a Register Nurse and an Administrator Scribe, two Spiritual Counselors and a Social Worker. The record documents an Interdisciplinary Group meeting on 04/25/2024 listed “;Participants electronic signatures; a Register Nurse, an Administrator Scribe and two Spiritual Counselors. There is no documented evidence of a Social Worker participating in all meetings and no electronic signature documented. There is no documented evidence of a Physician participating in meetings and no electronic signature documented. On 5/9/2024 at 3:30pm findings reviewed with the Administrator and Patient Service Manager; no addition information provided.”

“Based on record review and interviews, the Hospice failed to ensure all hospice care and services furnished to patient and their families follow an individualized written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (if any), the patients representation, and the primary caregiver in accordance with the patients needs if any of them so desire. This was evident in one (1) of fourteen (14) clinical records reviewed (Patient #3). Failure of the hospice to ensure all care and services furnished to patient and their families follow an individualized written plan of care established by the hospice interdisciplinary group has the potential for negative outcomes. The findings are: Patient #3 has a start of care date of 03/05/2024 with diagnoses of Alzheimers Disease Late onset, Dementia, Parkinsonism, Unspecified Atrial Fibrillation, Repeated Falls, Orthostatic Hypotension, Hyperlipidemia, Fracture of Ribs, left side, Long-term use of anti-coagulant, and Encounter for Palliative Care as documented on the “;Physicians Orders/Plan of Care” from 03/05/2024 to 06/02/2024. The “;Physicians Orders/Plan of Care” from 03/05/2024 to 06/02/2024 documents an order for Skilled Nurse 1-2x week x 13 weeks (one to two visits a week for thirteen weeks. Skilled Nurse to “;Assess location, intensity, duration, frequency, precipitating factors, and character of pain”. The “;Routine Visit” reports dated 03/11/24, 03/26/24,03/29/24, 04/04/23, 04/05/24, 04/12/24, and 04/19/24 lack documented evidence that the Skilled Nurse performed pain assessment of the Hospice patient. The clinical record lacks documented evidence of Skilled Nurse conducted visits 1-2 X week (one to two vists a week) from 03/12/24 – 03/25/24. The Hospice did not ensure that Skilled Nurse services assessed the patients pain status and provide Skilled Nurse visits 1-2 x week in accordance to the Plan of Care. The survey findings and interview were conducted on 05/08/2024 at 12:04 PM with the Administrator, Patient Service Manager and Senior Vice President. No explanation was provided.”

“Based on record reviews and staff interviews, the Hospice failed to ensure the development of an individualized written care plan for each patient that reflects the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessment. This was evident for four (4) of fourteen (14) clinical records reviewed (Patients #6, #7, #9, and #10). Failure to ensure the development of an individualized written care plan for each patient has the potential for negative outcomes. The findings are: 4) Patient # 10 has a Start of Care date of 09/05/2023 with diagnosis of Cerebral Atherosclerosis, Hypertension, Chronic Kidney Disease, Hyperlipemia and Unspecified Gout as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks,1 times per week for 1 week, MSS (Medical Social Services) 1 to 2 times per month for 3 months, SC (Spiritual Counselor) 1 to 2 times per month for 3 months and Aide 1 to 2 times per week for 1 week, 1 to 5 time per week for 8 weeks and 1 to 2 times per week times one week”. Routine Visit Note dated 03/11/2024 documents “;Patient denies having any shortness of breath, oxygen saturation 95% with concentrator oxygen in use during visit”. Routine Visit Note dated 04/08/2024 documents “;Patient denies having any shortness of breath at present time, oxygen saturation 90% with concentrator oxygen in use during visit”. Routine Visit Note dated 04/24/2024 documents “;Patient denies having any shortness of breath at present time, oxygen saturation 91% with concentrator oxygen in use during visit”. Routine Visit Note dated 04/08/2024 documents “;Patient denies having any shortness of breath at present time, oxygen saturation 90% with concentrator oxygen in use during visit”. The Plan of care lacked orders for Oxygen, administration, dosage, and delivery system. The Plan of care is incomplete and lacked orders for services needed and treatments, durable medical equipment, and medications. Interview conducted on 05/09/2024 at 3.30pm with the Patient Service Manager in response to no oxygen orders: the Manager stated, “;The Oxygen has been a rumor to be in the home and she will look into it.” On 5/9/2024 at 3:30pm findings reviewed with the Administrator and Patient Service Manager; no addition information provided. 1) Patient # 6 has a Start Of Care date of 3/12/2024 with diagnosis of “Thyrotoxicosis with diffuse goiter without Thyrotoxic crisis or storm, Hypothyroidism unspecified, Unspecified Dementia-unspecified severity without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 1 to 2 times per month for 4 months”. The clinical record lacks documented evidence of an Interdisciplinary Group/Attending Physician comprehensive assessment. 2) Patient # 7 has a Start Of Care date of 1/31/2024 with diagnosis of “Malignant Neoplasm of Bladder-Unspecified” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “01-31-24 to 04-29-24”. The Hospice “A. Certification Statement for the first 90-day period”, “Effective Date of Certification: 01-31-2024”, “Benefit Period From: 01-31-2024 To: 04-29-2024”. The clinical record lacks documented evidence of a current Plan of Care. The clinical record lacks documented evidence of a current Certification Period Statement. The clinical record lacks documented evidence of an updated Interdisciplinary Group/Attending Physician comprehensive assessment. 3) Patient # 9 has Start Of Care date of 1/4/2024 with a diagnosis of “Alzheimer’s Disease-unspecified” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “01-04-24 to 03-03-24”. The Hospice “C. Recertification Statement for 60-day period”, “Effective Date of Certification: 01-04-2024”, “Benefit Period From: 01-04-2024 To: 03-03-2024”. The clinical record lacks documented evidence of a current Plan of Care. The clinical record lacks documented evidence of a current Certification Period Statement. The clinical record lacks documented evidence of an updated Interdisciplinary Group/Attending Physician comprehensive assessment. On 5/9/2024 at 3:50pm findings and interview was conducted with the Administrator, no additional information received.”

“Based on record reviews and staff interviews, the Hospice failed to ensure the development of a plan of care detailing the scope and frequency of services necessary to meet the specific patient and family needs. This was evident for one (1) of fourteen (14) clinical records reviewed (Patient #11). Failure to ensure the development of a plan of care detailing the scope and frequency of services necessary to meet the specific patient and family needs has the potential for negative outcomes. The findings are: Patient #11 has a start of care date of 7/18/2023 and an date of death of 8/6/2023 with diagnoses that include Cerebral Atherosclerosis, Personal History of Transient Ischemic Attack and Cerebral Infarction without residual deficits, Gastrointestinal Hemorrhage as documented on the “; Physicians Orders / Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023. The “;Physicians Orders / Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023 documents:” Skilled Nurse: Assess / instruct patient/ family in disease process/progression and management of symptoms, assess level of discomfort and identify comfort goal assess patient/ family ability to provide effective personal care. Hospice Aide supervision at least every 14 days”. There is no documented evidence of the frequency of skilled nursing services to be provided to the patient. The Aide “;Assignment sheet” effective date 7/19/2023 documents:” hours /days of assignment: Monday, Tuesday, Wednesday, Thursday, Friday 1:00PM-5:00PM”. The “;Aide Duty sheets” document that aide services were provided from 7/19/2023 to 8/4/2023. There is no documented evidence of an order for aide services and the frequency of aide services in the Plan of Care. On 5/9/2024 at 3:30 PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on record reviews and staff interviews, the Hospice failed to ensure the hospice interdisciplinary group review, revise, and document the individualized plan as frequently as the patients condition requires, but no less frequently than every fifteen (15) calendar days. This was evident for two (2) of fourteen (14) clinical records reviewed (Patients #11 and #12). Failure to ensure the hospice interdisciplinary group review, revise, and document the individualized plan as frequently as the patients condition requires, but no less frequently than every fifteen (15) calendar days has the potential for negative outcomes. The findings are: 1) Patient #11 has a start of care date of 7/18/2023 and an expiration date of 8/6/2023 with diagnoses of Cerebral Atherosclerosis, Pulmonary Embolism, Gastrointestinal Hemorrhage as documented on the “;Physicians Orders/ Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023. The “;Physicians Orders/ Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023 documents:” Skilled Nursing: Skilled Nurse: Assess / instruct patient/ family in disease process/progression and management of symptoms, assess level of discomfort and identify comfort goal assess patient/ family ability to provide effective personal care. Hospice Aide supervision at least every 14 days”. The “;Charts/ Clinical Notes” dated 7/19/2023 Speech Therapy document:” Patient placed on Nothing By Mouth (NPO) by the Physician. Recommended continuing with Nothing by Mouth orders at this time. Communicated findings/ recommendations to the Physician, the Licensed Practical Nurse, and the Hospice team. Made Home Health aware of Nothing by Mouth orders who verbalized understanding. There is no documented evidence of an Interdisciplinary Group meeting to discuss the patient individualized plan of care. There is no documented evidence of the patient visit with the speech therapist and review/ revision of the Plan of Care at the Interdisciplinary Group meetings. The” Charts/ Clinical Notes” dated 7/20/2023 Skilled Nursing document:” Skin: Right bunion unstageable pressure ulcer and right Deep Tissue Injury”. Home Health Aide present at the bedside”. The” Charts/ Clinical Notes” dated 7/25/2023 Skilled Nursing document:” Skin: Right bunion unstageable pressure ulcer and right Deep Tissue Injury”. The” Charts/ Clinical Notes” dated 8/1/2023 Skilled Nursing document:” Patient continues to require assistance with Activities of Daily Living, incontinent of bladder and bowels, does not appear to be in pain or any discomfort, no edema or contractures noted to upper or lower extremities, skin remains intact”. There is no documented evidence of wound treatments for the pressure ulcers in the Plan of Care. There is no documented evidence the wound care and treatments were discussed at the Interdisciplinary Group meeting for review or revision of the Plan of Care. The Charts/ Clinical Notes” dated 7/28/2023 Medical Social Worker” document:” Discussed patient care with Interdisciplinary Team(IDT). Family request rabbi visit patient. Social worker left email to Recreation Director”. There is no documented evidence the family request and follow up with rabbi visit was discussed at the Interdisciplinary Group meetings. There is no documented evidence of interdisciplinary Group meeting to review/ revised the patients individualized Plan of Care. The “;Charts/ Clinical Notes” document: the following: 7/19/2023 Speech Therapy documents:” Made Home Health Aide aware of patient Nothing By Mouth orders”. 7/20/2023 Skilled Nursing” documents:” Home Health Aide at bedside”. 8/1/2023 Skilled Nursing documents:” Home Health Aide supervision with aide. Care plan reviewed”. There is no documented evidence of an order for Home health Services. There is no documented evidence of an aide Plan of Care. There is no documented evidence the aide services were discussed at the Interdisciplinary Group meetings so the Plan of Care can be reviewed or revised. There is no documented evidence of Interdisciplinary Group meetings. There is no documented evidence the Interdisciplinary has reviewed and revised the patient individualized Plan of Care. 2) Patient #12 has a start of care date of 11/2/2023 and an expiration date of 11/27/2023 with diagnoses that include Malignant neoplasm of Upper Lobe, Left Bronchus or Lung, Secondary Malignant Neoplasm of Bone, Secondary Neoplasm of Liver and Intrahepatic Bile Duct as documented on the “;Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 1/30/2024. The” Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 1/30/2024 documents:” Aide 1-2 x week for one week, 3-5 week for 11 weeks”. On 5/8/2023 at 3:30PM, the surveyor requested the Aide Plan of Care and the Aide activity sheets. This information was not received. There is no documented evidence the patients plan of care was discussed, reviewed or revised at the Interdisciplinary Group meetings to reflect the missed visits for aide services. The “;Charts/ Clinical Notes Medical Social Worker” visit note dated 11/24/2023 documents:” Writer visited patient at bedside to check status post fall. Patients family expressed concerns about patients management, and they were unclear about the medication’s orders and administration. Writer clarified with Registered Nurse that patient is on standing order for Morphine. Writer communicated to Registered Nurse that patient endorsed pain and patient brother requesting it is administered. This Social Worker requested family meeting, including Skilled Nursing Facility, Registered Nurse, and Social Worker as well as hospice Registered Nurse an Social Worker to clarify medications and Plan of Care to family”. There is no documented evidence the patients pain and family concerns over the medications were discussed at the Interdisciplinary Group meetings. There is no documented evidence of Interdisciplinary Group meetings to address the patients individualized Plan of Care. There is no documented evidence the Patient Plan of Care was reviewed and revised to address the patients needs for Hospice care. On 5/9/2023 at 3:45 PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on record reviews and staff interviews, the Hospice failed to ensure the care and services provided are in accordance with the plan of care. This was evident for four (4) of fourteen (14) clinical records reviewed (Patients #2, #10, #12, and #13). Failure to ensure the care and services provided are in accordance with the plan of care has the potential for negative outcomes. The findings are: 3) Patient #12 has a start of care date of 11/2/2023 and an expiration date of 11/27/ 2023 with diagnoses that include Malignant neoplasm of Upper Lobe, Left Bronchus or Lung, Secondary Malignant Neoplasm of Bone, Secondary Neoplasm of Liver and Intrahepatic Bile Duct as documented on the “;Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 12/1/2023. The” Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 12/1/2023 documents:” Aide 1-2 x week for one week, 3-5 week for 11 weeks”. On 5/8/2023 at 3:30PM, the surveyor requested the Aide Plan of Care and the Aide activity sheets. This information was not received. There is no documented evidence that aides services were provided in accordance with the Plan of Care. 4) Patient #13 has a start of care date of 8/24/2023 and a discharge date of 11/17/2023 with diagnoses that include Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Cardiogenic Shock, Pulmonary Hypertension as documented on the” Physicians Orders / Plan of Care” for the Certification Period of 8/24/2023 to 11/21/2023. The “Physicians Orders / Plan of Care” for the Certification Period of 8/24/2023 to 11/21/2023 documents:” Skilled Nurse 1-2 times a week for 13 weeks. Assess/instruct patient /family in disease process/ progression and management of symptoms. Assess level of comfort/discomfort and identify comfort goal. Assess location, intensity, duration, frequency, precipitating factors and character of pain”. The “ Hospice Routine Visit” document the following skilled nursing visits: 8/28/2023, 8/2023, 9/21/2023,10/18/2023, 10/24/2023, 10/31/2023. There is no documented evidence of skilled nursing visits for the following: Week of 9/9/2023 to 9/15/2023. Week of 9/23/2023 to 9/29/2023. Week of 10/7/2023 to 11/13/2023. There is no documented evidence the skilled nursing services were provided in accordance with the Plan of Care. On 5/9/2024 at 3:45 PM, the Administrator was interviewed and did not provide an explanation for the findings.. 1) Patient # 2 has a Start of Care date of 11/10/2023 with diagnosis of Malignant Neoplasm of female Breast with Metastasis to Bone, Schizophrenia, Depression, Type 2 Diabetes, Hyperlipidemia as documented on the Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24”. The Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 3 times per month for 4 months and Aide 1 to 3 times per week for 1 week, 1 to 5 time per week for 12 weeks”. The” Hospice Routine Visit” document the following skilled nursing visits: 2/08/2024, 2/22/24, 3/07/2024,3/13/24, 3/26/24, 4/102/24, 4/09/24, 4/16/24, 4/24/24, 5/01/24 and “;On call/Unscheduled” visit dated 5/07/24. There is no documented evidence of skilled nursing visits for the following: Week of 2/11/2024 to 2/17/2024. Week of 2/25/2024 to 3/02/2024. Week of 3/17/2024 to 3/23/2024. There is no documented evidence the skilled nursing services were provided in accordance with the Plan of Care. 2) Patient # 10 has a Start of Care date of 09/05/2023 with diagnosis of Cerebral Atherosclerosis, Hypertension, Chronic Kidney Disease, Hyperlipemia and Unspecified Gout as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks,1 times per week for 1 week, MSS (Medical Social Services) 1 to 2 times per month for 3 months, SC (Spiritual Counselor) 1 to 2 times per month for 3 months and Aide 1 to 2 times per week for 1 week, 1 to 5 time per week for 8 weeks and 1 to 2 times per week times one week “. Aide plan of care dated 01/09/2024 documents hospice aide service 5 days per week times 4 hours (Monday to Friday) to assist patient with “;bathing/shower, oral/hair/skin care, meal prep, assist patient with eating, turn and position, assist with transfer and ambulation”. Aide activity sheets and patient calendar documents the last aide visit on “;03/28/2024”. On 5/08/2024 at 3.30 PM, the surveyor requested all of aides activity sheets and documentation of aide service discharge or any documentation that patient did not want aide services. Aide activity sheets for weeks of: 01/22/24 to 01/25/24, 3/4/24 to 3/7/24, 3/11/24 to 3/14/24, 3/1824 to 3/21/24 and 3/25/24 to 3/28/24 lacks documented evidence of the aide providing care as directed by the plan of care to include bathing/shower, oral/hair/skin care, meal prep, assist patient with eating, turn and position, assist with transfer and ambulation. The record lacked all of aides activity sheets and care provided was inconsistent. On 5/9/2024 at 3:30pm findings reviewed with the Administrator and Patient Service Manager; no addition information provided.”

“Based on record reviews and staff interviews, the Hospice failed to ensure the hospice provides for and ensures the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. This was evident for eight (8) of fourteen (14) clinical records reviewed (Patients #2, #3, #4, #5, #10, #11, #12, and #13). Failure to ensure the hospice provides for and ensures the ongoing sharing of information between all disciplines providing care and services in all settings has the potential for negative outcomes. The findings are: 6) Patient #11 has a start of care date of 7/18/2023 and an expiration date of 8/6/2023 with diagnoses that include Cerebral Atherosclerosis, Personal History of Transient Ischemic Attack and Cerebral Infarction without residual deficits, Gastrointestinal Hemorrhage as documented on the “; Physicians Orders / Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023. The “;Physicians Orders / Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023 documents:” Skilled Nurse assess /instruct patient family in disease process/ progression and management of symptoms. Medical Social Worker: Encourage ventilation of feelings/ fears, provide immediate, emotional support and reassurance to patient/ family”. The “ Charts / Clinical Notes” dated 7/18/2023 Skilled Nursing document:” Right Heel Deep Tissue Injury (DTI) measuring 1x0.5x0”. The” Charts/ Clinical Notes” dated 7/20/2023 Skilled Nursing document:” Skin: Right bunion unstageable pressure ulcer and right Deep Tissue Injury”. Home Health Aide present at the bedside”. The” Charts/ Clinical Notes” dated 7/25/2023 Skilled Nursing document:” Skin: Right bunion unstageable pressure ulcer and right Deep Tissue Injury”. The “ Charts/ Clinical Notes” dated 8/1/2023 Skilled Nursing document:” Patient continues to require assistance with Activities of Daily Living, incontinent of bladder and bowels, does not appear to be in pain or any discomfort, no edema or contractures noted to upper or lower extremities, skin remains intact”. There is no documented evidence of wound treatments for the pressure ulcers in the Plan of Care. There is no documented evidence the wound care and treatments were discussed at the Interdisciplinary Group meeting for review or revision of the Plan of Care. There is no documented evidence of discussion of pressure ulcers treatments with the Skilled Nursing Facility. The Charts/ Clinical Notes” dated 7/28/2023 Medical Social Worker” document:” Discussed patient care with Interdisciplinary Team( IDT). Family request rabbi visit patient. Social worker left email to Recreation Director”. There is no documented evidence the family request and follow up with rabbi visit was discussed at the Interdisciplinary Group meetings. The “; Charts/ Clinical Notes” document: the following: 7/19/2023 Speech Therapy documents:” Made Home Health Aide aware of patient Nothing By Mouth orders”. 7/20/2023 Skilled Nursing” documents:” Home Health Aide at bedside”. 8/1/2023 Skilled Nursing documents:” Home Health Aide supervision with aide. Care plan reviewed”. There is no documented evidence of ongoing sharing of information between all disciplines providing care and services and non Hospice providers. 7) Patient #12 has a start of care date of 11/2/2023 and an expiration date of 11/27/2023 with diagnoses that include Cancer of the Lung, Secondary Malignant Neoplasm of the Bone as documented on the “; Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 1/30/2024. The “;Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 1/30/2024 documents:” Skilled Nursing 1-2 x week for 12 weeks. Medical Social Worker 1-2x month for 3 months. Aide 1-2x week for one week, 3-5x week for 11 weeks Spiritual Care 1-2 x months x 3 months”. The “;Charts/ Clinical Notes” Medical Social Worker document:” Social Worker visited patient status post fall”. There is no documented evidence the fall occurrence was communicated to the hospice nurse for follow-up. There is no documented evidence of communication with the Skilled Nursing Facility about the circumstances surrounding the fall . There is no documented evidence the Social Worker has shared this information with the Nurse the Physician and the Hospice team. There is no documented evidence of ongoing sharing of information between all disciplines providing care and services to the Hospice patient. 8) Patient #13 has a start of care date of 8/24/2023 and a discharge date of 11/17/2023 with diagnoses that include Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Cardiogenic Shock, Pulmonary Hypertension as documented on the” Physicians Orders / Plan of Care” for the Certification Period of 8/24/2023 to 11/21/2023. The “Physicians Orders / Plan of Care” for the Certification Period of 8/24/2023 to 11/21/2023 documents:” Skilled Nurse 1-2 times a week for 13 weeks. Medical Social Worker 1-4x month for 4 months.”. The” Notice of Medicare Non Coverage” dated 11/17/203 document: “;Effective 11/17/2023 your current Hospice Coverage will end”. There is no documented evidence of a clinical note that this information was shared with the Physician, the Nurse, and the Skilled Nursing Facility for post – discharge continuity of care There is no documented evidence of ongoing sharing of information between all disciplines providing care and services and non-Hospice provider. On 5/9/2023 at 3:30PM, the Administrator was interviewed and did not provide an explanation for the findings. 3) Patient #3 has a start of care date of 03/05/2024 with diagnoses of Alzheimers Disease Late onset, Dementia, Parkinsonism, Unspecified Atrial Fibrillation, Repeated Falls, Orthostatic Hypotension, Hyperlipidemia, Fracture of Ribs, left side, Long-term use of anti-coagulant, and Encounter for Palliative Care as documented on the “;Physicians Orders/Plan of Care” from 03/05/2024 to 06/02/2024. The “;Physicians Orders/Plan of Care” from 03/05/2024 to 06/02/2024 documents an order for Skilled Nurse 1-2x week x 13 weeks (one to two visits a week for thirteen weeks), Medical Social Services 1- 2x month for 3 months (one to four times a month for three months), Aide (Hospice Service Aide) 3 – 5 x week x 13 weeks (three to five times a week for thirteen weeks), Spiritual Counseling 1-2 x month x 3 months (one to two times a month for three months)”. The “Case Conference Summary Report” (Interdisciplinary Group) dated 03/07/2024 documents “clinical notes” entry by the Hospice Medical Doctor date 03/05/24 and Skilled Nurse dated 03/05/24. There is no clinical note entry by the Medical Social Worker and Spiritual Counseling. The Interdisciplinary Group meeting dated 03/07/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 03/14/2024 documents “clinical notes” new entry by the Skilled Nurse dated 03/11/24, Medical Social Worker dated 03/12/24, and Spiritual Counseling 03/13/24. The Interdisciplinary Group meeting dated 03/14/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 03/28/2024 documents “clinical notes” new entry by the Skilled Nurse dated 03/26/24, Medical Social Worker dated 03/26/24, and Spiritual Counseling 03/27/24. The Interdisciplinary Group meeting dated 03/28/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 04/11/2024 documents “clinical notes” new entry by the Skilled Nurse dated 03/29/34, 04/04/24, and 04/05/24. Medical Social Worker dated 04/05/24. The Interdisciplinary Group meeting dated 04/11/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 04/25/2024 documents “clinical notes” new entry by the Skilled Nurse dated 04/12/24, 04/19/24, 04/22/24. Medical Social Worker dated 04/12/24, 04/17/24, 04/24/24, and Spiritual Counseling dated 04/22/24. The Interdisciplinary Group meeting dated 04/25/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The Interdisciplinary Group reports lack documented evidence of discussion, communication, coordination, and integration of Hospice services. The survey findings and interview were conducted on 05/08/2024 at 12:04 PM with the Administrator, Patient Service Manager and Senior Vice President. No explanation was provided. 4) Patient #4 has a start of care date of 12/05/2023 with diagnoses of Heart failure, COVID -19, Alzheimers Disease, Unspecified Dementia, Hypertensive Heart Disease, Acute Chronic Diastolic Heart Failure, Essential Hypertension and Muscle Weakness as documented on the “;Physicians Orders/Plan of Care” from 03/04/24 to 06/01/24. The “;Physicians Orders/Plan of Care” from 03/04/24 to 06/01/24 documents orders for “;Skilled Nurse 1-2x week x 13 weeks (one to two visits a week for thirteen weeks), Medical Social Services 1- 2x month for 3 months (one to four times a month for three months), Aide (Hospice Service Aide) 3 – 5 x week x 13 weeks (three to five times a week for thirteen weeks), Spiritual Counseling 1-2 x month x 3 months (one to two times a month for three months)”. The “Case Conference Summary Report” (Interdisciplinary Group) dated 03/14/24documents “clinical notes” new entry by the Medical Director dated 03/04/24, Skilled Nurse dated 03/07/24, 03/12/24, Spiritual Counseling dated 03/07/24, and Medical Social Worker dated 03/11/24. The Interdisciplinary Group meeting dated 03/14/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 03/28/24 documents “clinical notes” new entry by the Skilled Nurse dated 03/26/24, Medical Social Worker dated 03/25/24. There is no clinical note entry by the Spiritual Counseling. The Interdisciplinary Group meeting dated 03/28/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 04/11/24 documents “clinical notes” new entry by the Skilled Nurse dated 04/09/24, Medical Social Worker 04/10/24. There is no clinical note entry by the Spiritual Counseling. The Interdisciplinary Group meeting dated 04/11/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 04/25/24 documents “clinical notes” new entry by the Skilled Nurse dated 04/22/24, Spiritual Counseling dated 04/23/24 and Medical Social Worker 04/23/24. The Interdisciplinary Group meeting dated 04/25/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The survey findings and interview were conducted on 05/09/2024 at 03:56 PM with the Administrator, Patient Service Manager and Senior Vice President. No explanation was provided. 5) Patient #5 has a start of care date of Cerebral Atherosclerosis as documented on the “;Physicians Orders/Plan of Care” from 04/03/2024 to 07/01/2024. The “;Physicians Orders/Plan of Care” from 04/03/2024 to 07/01/2024 documents orders for “;Skilled Nurse 1-2x week x 13 weeks (one to two visits a week for thirteen weeks), Medical Social Services 1- 2x month for 3 months (one to four times a month for three months), Aide (Hospice Service Aide) 3 – 5 x week x 13 weeks (three to five times a week for thirteen weeks), Spiritual Counseling 1-2 x month x 3 months (one to two times a month for three months)”. The “Case Conference Summary Report” (Interdisciplinary Group) dated 04/11/2024 documents “clinical notes” entry by the Medical Director dated 04/03/24, Skilled Nurse dated 04/03/24, 04/08/24, 04/10/24, Medical Social Worker dated 04/05/24, and Spiritual Counseling dated 04/08/24. The Interdisciplinary Group meeting dated 04/11/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 04/25/24 documents “clinical notes” new entry by the Skilled Nurse dated 04/15/24,0 4/19/24, 04/22/24. Spiritual Counseling dated 04/22/24, and Medical Social Worker dated 04/24/24. The Interdisciplinary Group meeting dated 04/25/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The survey findings and interview were conducted on 05/09/2024 at 04:03 PM with the Administrator, Patient Service Manager and Senior Vice President. No explanation was provided. 1) Patient # 2 has a Start of Care date of 11/10/2023 with diagnosis of Malignant Neoplasm of female Breast with Metastasis to Bone, Schizophrenia, Depression, Type 2 Diabetes, Hyperlipidemia as documented on the Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24”. The Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 3 times per month for 4 months and Aide 1 to 3 times per week for 1 week, 1 to 5 time per week for 12 weeks”. The “Case Conference Summary Report” (Interdisciplinary Group) dated 11/16/2023 documents “clinical notes” entry by the Hospice Social Worker dated 11/13/23, Skilled Nurse dated 11/10/23, and Spiritual Counseling dated 11/13/23. There is no clinical note entry by the Medical Doctor. The Interdisciplinary Group meeting dated 11/16/23 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The Interdisciplinary Group reports lack documented evidence of discussion, communication, coordination, and integration of Hospice services. The “Case Conference Summary Report” (Interdisciplinary Group) dated 04/25/2024 documents “clinical notes” new entry by the Skilled Nurse dated 03/26/24, 4/02/24, 4/09/24 and 4/16/24, Medical Social Worker dated 04/17/24, and Spiritual Counseling dated 04/24/24 and Medical Doctor dated 4/1/2024. The Interdisciplinary Group meeting dated 04/25/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The Interdisciplinary Group reports lack documented evidence of discussion, communication, coordination, and integration of Hospice services. 2) Patient # 10 has a Start of Care date of 09/05/2023 with diagnosis of Cerebral Atherosclerosis, Hypertension, Chronic Kidney Disease, Hyperlipemia and Unspecified Gout as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks,1 times per week for 1 week, MSS (Medical Social Services) 1 to 2 times per month for 3 months, SC (Spiritual Counselor) 1 to 2 times per month for 3 months and Aide 1 to 2 times per week for 1 week, 1 to 5 times per week for 8 weeks and 1 to 2 times per week times one week”. The “Case Conference Summary Report” (Interdisciplinary Group) dated 01/11/2024 documents “clinical notes” entries; Skilled Nurse dated 12/13/23, 12/21/23, 1/08/24, Nurse Practitioner dated 12/30/24, Medical Doctor dated 01/08/24. There are no Social Worker and Spiritual Counselor clinical note entries. The Interdisciplinary Group meeting dated 01/11/2024 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The Interdisciplinary Group reports lack documented evidence of discussion, communication, coordination, and integration of Hospice services. In the “Case Conference Summary Report” (Interdisciplinary Group) dated 04/25/2024, the Social Worker documents “patient refused social worker services”. “Clinical notes” entries by Skilled Nurse dated 4/08/24, 4/17/24 and 4/19/24 and 4/24/24, and Nurse Practitioner dated 4/10/24. No clinical note entries by Spiritual Counseling and Medical Doctor. The Interdisciplinary Group meeting dated 04/25/24 lack documented evidence of discussion among the ordered disciplines about the patient’s status and Hospice services. The Interdisciplinary Group reports lack documented evidence of discussion, communication, coordination, and integration of Hospice services. On 5/9/2024 at 3:30pm findings reviewed with the Administrator and Patient Service Manager; no addition information provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes for 2023 and 2024, and interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure Quality Assessment and Performance Improvement initiatives are in place to measure improvement related to palliative outcomes and Hospice services. Failure to develop a comprehensive Quality Assessment and Performance Improvement Program that documents measurable improvement in indicators related to improved Palliative outcomes and Hospice services hinders the Hospice’s ability to determine what Quality Assessment and Performance Improvement interventions have been successful and identify areas in need of improvement, has the potential for negative patient outcomes. The findings are: The Hospice documents a “Quality Assurance Performance Improvement Plan; Effective Date: April 1, 2024”. The hospice failed to implement the program and has not shown measurable improvements in palliative outcomes and hospice services. The Hospice lacks documented evidence of a Quality Improvement and Performance Improvement Policy or Plan prior to April 1, 2024. A policy or plan for prior to April 1, 2024 was requested by the surveyor on 05/07/2024 at 10:30AM, no additional documentation was received. The Administrator/Director of Patient Services was interviewed on 05/07/2024 at 3:30PM and stated “;prior to April we didnt have a plan or Performance Improvement Projects, we recognized the need and changed the way we do Quality Improvement and Performance Improvement”.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes for 2023 to 2024, and interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure quality indicators, including adverse patient events are measured, analyzed and tracked. Failure to measure, analyze and track quality indicators, including adverse events, hinders the Hospice’s ability to identify areas of needed improvement and has the potential for negative patient outcomes, adversely affecting care services and operations. The findings are: The Hospice lacks documented evidence of a Quality Improvement and Performance Improvement Policy or Plan prior to April 1, 2024. A policy or plan for prior to April 1, 2024 was requested by the surveyor on 05/07/2024 at 10:30AM, no additional documentation was received. The Quality Assessment and Performance Improvement (QAPI) meeting minutes (dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 04/16/2024) lack documented evidence the Hospice has developed and documented in writing of quality indicators in areas of operation that might affect patient care, such as pain assessment, volunteer availability and adverse events that is measured, analyzed, and tracked. The Quality Assurance and Performance Improvement (QAPI) meeting minutes (dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 04/16/2024) lack documented evidence the Hospice has developed and documented in writing specific definitions of adverse events, such as falls with and without injury and active infections. On 05/08/2024 at 12:10PM the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the above findings. No additional evidence was provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes and initiatives for 2023 to 2024, and interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure quality indicators for data collection have been developed relevant to all facets of a Hospice operation, including all patient services and interventions that may impact patient care. Failure to ensure the data collection of quality indicators are relevant to all facets of the Hospice operation has the potential for negative patient outcomes and adversely affecting organizational operations. The findings are: A review of the 2023 to 2024 Quality Assurance and Performance Improvement (QAPI) meeting minutes (dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 04/16/2024) lack documented evidence the committee developed quality indicators for data collection. The meeting minutes lack documented evidence the committee collected data regarding physician services, nursing services, medical social service, counseling services, infection control, pharmaceutical services, durable medical equipment (DME), patient rights, administrative services, contract services, or volunteer services to assist in identifying areas in need of improvement. On 05/08/2024 at 12:10PM, the Administrator/Director of Patient Services was interviewed and did not provide and explanation for the above findings. No additional evidence was provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes and initiatives for 2023 to 2024, and interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure that the data collected during Quality Performance Improvement initiatives was used to identify areas for improvement. Failure to use the data collected to monitor the effectiveness and safety of services and quality of care, or identify opportunities and priorities for improvement, has the potential for negative patient outcomes. A review of the 2023 to 2024 Quality Assessment and Performance Improvement (QAPI) meeting minutes (dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 04/16/2024) lack documented evidence the committee collected data to identify a need for improvement in areas of need such as physician, nursing, medical social work, spiritual counseling, infection control, pharmaceutical, durable medical equipment, patient rights, administrative services, contract, volunteer, and adverse events to monitor the effectiveness and safety of services, quality of care, and to identify opportunities for improvement. On 05/08/2024 at 12:10PM, the Administrator/Director of Patient Services was interviewed and did not provide and explanation for the above findings. No additional evidence was provided.”

“Based on review of the agency’s Quality Assessment and Performance Improvement Program and activities for 2023 to 2024, and interview with the hospice Administrator/ Director of Patient Services, the Governing Authority failed to ensure performance improvement activities focused on high risk, high volume or problem prone areas. Failure to ensure performance improvement activities are focused on high risk, high volume or problem prone areas has the potential to result in negative patient outcomes. The findings are: A review of the 2023 to 2024 Quality Assessment and Performance Improvement (QAPI) meeting minutes (dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 04/16/2024) lack documented evidence the committee ensured data is collected, reviewed, and analyzed regarding high risk, problem-prone patient care areas such as patients receiving wound therapy, patients receiving spiritual care, patients with falls, or infection rates to determine if these are areas in need of improvement. The current data collection is of insufficient scope to identify high risk, high volume or problem-prone areas. There is no documented evidence of analysis of the data in the meetings minutes to identify any opportunities for improvement and implementation of preventive actions that include feedback and review the plan to ensure the outcome results of the care provided to patients receiving Hospice care. On 05/08/2024 at 4:10PM, the Administrator/Director of Patient Services was interviewed and did not provide and explanation for the above findings. No additional evidence was provided.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement activities for 2023 to 2024, interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure performance improvement activities considered the incidence, prevalence and severity of the problems in high risk, high volume and problem-prone areas. Failure to consider the incidence, prevalence, and severity of problems in high risk, high volume and problem-prone areas inhibits the hospice’s ability to identify areas of needed improvement in a timely manner and has the potential for negative patient outcomes. The findings are: A review of the 2023 to 2024 Quality Assessment and Performance Improvement (QAPI) meeting minutes dated 04/27/2023, 07/27/2023, and 01/25/2024 document the agency is scoring below national benchmark for pain assessment and comprehensive assessment. On 05/08/2024 at 4:10PM, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 to 2024 and interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure performance improvement interventions were tracked to ensure measurable improvements based on the data collected. Failure to implement and track interventions inhibits the Hospice’s ability to measure improvement has the potential to result in negative patient outcomes. The findings are: A review of the Quality Assessment and Performance Improvement (QAPI) meeting minutes dated 04/27/2023, 07/27/2023, and 01/25/2024 document the agency is scoring below national benchmark for pain assessment and comprehensive assessment. There is no documented evidence this data was used to develop and track interventions to ensure improved compliance with the measures. A review of the Quality Assessment and Performance Improvement (QAPI) meeting minutes dated 03/08/2024 documents record audits for Home Health Aide Care Plan completion and Advance Directives completion and a correction action for each measure. A review of the Quality Assessment and Performance Improvement (QAPI) meeting minutes dated 04/16/2024 lacks documented evidence of any documentation of record audits to track interventions initiated. There is no documented evidence the hospice initiated quality assessment and performance improvement initiatives focused on affecting palliative outcomes, patient safety, and quality of care. On 05/08/2024 at 4:10PM, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 to 2024, and interview with the hospice Administrator/Director of Patient Services, the Hospice failed to ensure Performance Improvement Projects were of sufficient scope to address the needs of the patient population improve the care of the patients receiving hospice services. Failure to develop Performance Improvement Projects that address the needs of the patient receiving hospice care or services has the potential for negative patient outcomes. The findings are: A review of the 2023 to 2024 Quality Assessment and Performance Improvement (QAPI) meeting minutes (dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 04/16/2024) lack documented evidence that sufficient data, including evaluating all aspects of patient service and activities that may impact patient and family care and all facets of the hospice’s operation, was collected and quality indicators established and utilized to determine what performance improvement projects would be appropriate to improve quality of care and improve the non-clinical operations of the hospice. On 05/08/2024 at 4:10PM, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 to 2024, and interview with the Hospice Administrator/Director of Patient Services, the Hospice failed to measure its success and track its performance improvement interventions based on the data collected to ensure that improvements are sustained. Failure to measure its success and track its performance improvement interventions to ensure that improvements are sustained based on the data collected has the potential for negative patient outcomes. The findings are: A review of the Quality Assessment and Performance Improvement (QAPI) meeting minutes dated 04/27/2023, 07/27/2023, and 01/25/2024 document the agency is scoring below national benchmark for pain assessment and comprehensive assessment. There is no documented evidence this data was used to develop and track interventions to ensure improved compliance with the measures. A review of the Quality Assessment and Performance Improvement (QAPI) meeting minutes dated 03/08/2024 documents record audits for Home Health Aide Care Plan completion and Advance Directives completion and a correction action for each measure. A review of the Quality Assessment and Performance Improvement (QAPI) meeting minutes dated 04/16/2024 lacks documented evidence of any documentation of record audits to track interventions initiated. On 05/08/2024 at 4:10PM, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 to 2024 and interview with the Hospice Administrator/Director of Patient Services, the Hospice failed to develop, implement and evaluate performance improvement projects that address the needs of the patient receiving hospice care. Failure to develop, implement, and evaluate performance improvement projects that address the needs of the patient receiving hospice care has the potential to result in negative patient outcomes. The findings are: The Quality Assessment and Performance Improvement meeting minutes dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 4/16/2024 lacks documented evidence that formal performance improvement projects were developed to address adverse events, pain screening, and comprehensive assessment completion. On 05/08/2024 at 4:10PM, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 to 2024 and interview with the Hospice Administrator/Director of Patient Services, the Hospice failed to ensure Performance Improvement Projects were of sufficient scope to address the needs of the patient and improve hospice care and services. Failure to develop Performance Improvement Projects that address the needs of the patient and improve hospice care and services has the potential to result in negative patient outcomes. The findings are: The Quality Assessment and Performance Improvement meeting minutes dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 4/16/2024 and the Quality Assurance Performance Improvement Plan 2024 lack documented evidence that the number and scope of distinct performance improvement projects conducted annually is based on the needs of the hospice’s population and internal organizational needs or reflect the scope, complexity, and past performance of the hospice’s services and operations. On 05/08/2024 at 4:10PM, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“The findings are: The Performance Improvement Team Process “;Find the Problem and/or Opportunity to Change” dated 01/02/2024 documents Home Health Aide care plan completion and Advanced Directives documentation as identified problems. The Quality Assessment and Performance Improvement meeting minutes dated 03/28/2024 documents that audits were performed on eight (8) active patients in February 2024 for Home Health Aide Care Plan completion and on seventeen (17) active patients for Advance Directives completion. The Performance Improvement project solutions for the Home Health Aide Care Plan are to “;verify timely completion of the Home Health Aide (HHA) Care Plan and audit patients charts monthly to ensure the Home Health Aide Care Plan was completed timely and uploaded to patients charts timely as attachments”. The Performance Improvement project solutions for Advanced Directives are to “;audit patients charts monthly to ensure the Home Health Aide Care Plan was completed timely and uploaded to patients charts timely as attachments and maintain and update the Advanced Directives list as needed”. During an interview on 05/09/2024 at 1:20PM, the Administrator/Director of Patient Services was asked to provide documentation for the audits of Home Health Aide Care Plan and Advanced Directives. The agency did not provide evidence that it measured the identified performance improvement projects. The agency lacks documented evidence of measurable progress achieved on performance improvement projects and evaluation of interventions implemented to achieve the goal. On 05/08/2024 at 4:10PM, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 to 2024 and interview with the Hospice Administrator/Director of Patient Services, the Governing Body failed to ensure Quality Assessment and Performance program activities for patient safety are defined, implemented, maintained, and evaluated annually. Failure of the Governing Body to ensure Quality Assessment and Improvement activities for patient safety are defined, implemented, maintained, and evaluated annually has the potential for negative patient outcomes. The findings are: The Hospice lacks documented evidence of a Quality Improvement and Performance Improvement Policy or Plan prior to April 1, 2024. A policy or plan for prior to April 1, 2024 was requested by the surveyor on 05/07/2024 at 10:30AM, no additional documentation was received. The Administrator/Director of Patient Services was interviewed on 05/07/2024 at 3:30PM and stated “;prior to April we didnt have a plan or Performance Improvement Projects, we recognized the need and changed the way we do Quality Improvement and Performance Improvement”. There is no documented evidence the Hospice’s Quality Assessment and Performance Improvement for patient safety is being evaluated annually by the Governing Body. The Governing Body failed to ensure an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. The survey findings were reviewed at the exit conference on 05/10/2024 at 3:05PM.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 and interview with the hospice Administrator/ Director of Patient Services, the Governing Body failed to ensure Quality Assessment and Performance Improvement program activities address priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness. Failure of the Governing Body to ensure Quality Assessment and Performance Improvement activities are prioritized to improve quality of care and patient safety, and that all improvement actions are evaluated for effectiveness has the potential for negative patient outcomes. The findings are: The Quality Assessment and Performance Improvement meeting minutes dated 04/27/2023, 07/27/2023, 01/25/2024, 03/28/2024, and 04/16/2024 lacks documented evidence that hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. The agencys “;Quality Assurance Performance Improvement Plan” effective April 1, 2024 lacks documented evidence that hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. There is no documented evidence of the Governing Body oversight of the hospice’s improvement priorities for improved quality care and patient safety. There is no documented evidence the Governing Body evaluated the improvement actions for their effectiveness. On 05/09/2024 at 1:10PM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on home visit observation, employee record review, and staff interview, the hospice failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases. The regulatory provisions as defined in Section 2.59 of the State Sanitary Code within Title 10 of the New York Codes Rules and Regulations (10 NYCRR) required unvaccinated direct care providers to wear a mask during influenza season as declared by the Commissioner of Health. This was evident in two (2) of three (3) observational home visits (Patients #1 and #2) and two (2) of nine (9) employee records reviewed (Employees #2 and #3). Failure to follow accepted standards of practice to prevent the transmission of infections and communicable diseases places patients at risk for negative patient outcomes. The findings are: 2) Employee #3 has a hire date of 2/7/2023 as a Medical Social Worker. On 5/8/2024 at 12:00PM during an observational home visit of Patient #1, the surveyor observed the Employee not wearing a mask. The Employee declined the Influenza on 2/1/2024 for the Influenza season of 2023-2024. There is no documented evidence the Employee was supervised for wearing a mask during the Influenza season. Influenza was declared prevalent by the New York State Department of Health on 12/06/2023. The mask mandate was lifted on 05/08/2024 at 11:38AM. On 05/10/2024 at 12:25PM the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the above findings. No additional evidence was provided. 1) Employee #2 is a Registered Nurse with a hire date of 04/08/2019. On 05/07/2024 at 1:00PM during an in-home visit of Patient #2 conducted by the Surveyor with the Registered Nurse, the hospice nurse was not wearing a surgical mask. The agencys staff influenza roster provided by the agency on 05/08/2024 documents Employee #2 “;refused influenza vaccination”. The record lacks documented evidence of a signed flu declination and education form.”

“Based on employee record review and staff interview, the hospice failed to provide infection control education to employees and contracted providers. This was evident in four (4) of nine (9) employee records reviewed (Employees #2, #4, #7, and #8). Failure to provide infection control education to employees and contracted providers has the potential for negative patient outcomes. The findings are: 4) Employee # 8 has a hire date of 2/7/2023 as a Chaplain. The employee record lacks documented evidence of Annual Human Immunodeficiency Virus Training. On 5/10/2024 at 12:00 pm findings and interview was conducted with the Administrator, no additional information received. 3) Employee #7 is a Home Health Aide with a date of hire unknown. The Employee record lacks documented evidence of required Inservice on infection control and Human Immunodeficiency Virus Inservice On 5/10/2024, at 11:15 AM, the Administrator was interviewed and did not provide an explanation for the findings. 1) Employee #2 is a Registered Nurse with a hire date of 04/08/2019. The employee record lacks documented evidence of required annual in-services for Human Immunodeficiency (HIV) confidentiality and infection control for 2020, 2021, 2022, 2023. 2) Employee #4 is a Hospice Aide with hired date of 10/04/2023. The employee record lacks documented evidence of required orientation training and annual in-services for Human Immunodeficiency (HIV) confidentiality and infection control. On 5/10/2024 at 12.00 PM findings reviewed with the Administrator and Clinical Manager; no addition information provided.”

“Based on record review and interview with the Administrator/Director of Patient Services, the Hospice failed to ensure counseling services are made available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. This was evident for five (5) of fourteen (14) clinical records reviewed (Patients, #1, #8, # 11, #12, and #14). Failure to ensure counseling services are made available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process has the potential for negative outcomes. The findings are: On 5/8/2024 at 11:35 AM, The surveyor reviewed the Bereavement policy. The policy document:” Unless bereavement services have been refused a bereavement counselor, chaplain, or Social Worker will call designated bereaved to continue bereavement supportive services. A bereavement plan of care will be initiated which may include telephone support, letter and cards, referral to community resources, memorial services, bereavement camps, telephone contacts, individual or family counseling and bereavement groups. The plan of care will not the kind of bereavement services to be offered and frequency of service delivery”. 4) Patient #11 has a start of care date of 7/18/2023 and an expiration date of 8/6/2023. There is no documented evidence of a bereavement Plan of Care initiated on the initial bereavement risk assessment. There is no documented evidence of the kind of bereavement services offered and the frequency of services. 5) Patient #12 has a start of care date of 11/2/2023 and an expiration date of 11/27/ 2023. There is no documented evidence of a bereavement assessment into the comprehensive assessment. There is no documented evidence of a bereavement Plan of Care. There is no documented evidence of ongoing bereavement assessments. There is no documented evidence of bereavement services to be offered and frequency of service delivery On 5/9/2024 at 4:00PM, the Administrator was interviewed and did not provide an explanation for the findings. 1) Patient #1 has a start of care date of 1/9/2024 with diagnoses including Advanced Dementia, Weight Loss as documented on the “Orders/Plan of Care with a certification period of 3/9/20-05/07/24.” Medical record review did not include psycho-social assessment of family coping mechanism, adjustment or lack of adjustment to terminal illness. The hospice failed to make available, counseling services to family/caregiver to minimize stress associated with caring for terminally-ill. 2) Patient #8 has a start of care date of 3/6/2024 with diagnoses including Myeloproliferative Disorder, and Advanced Dementia as documented on the “Orders/Plan of care certification period of 3/6/2024-6/3/2024.” Medical record review did not include psycho-social assessment of family coping mechanism, adjustment or lack of adjustment to terminal illness. The hospice failed to make available, counseling services to family/caregiver to minimize stress associated with caring for terminally-ill. 3) Patient # 14 with a start of care date of 11/30/2023 with diagnoses including Cerebral Atherosclerosis, Dementia with functional decline as documented on the “Orders/Plan of Care recertification period of 1/29/2024-3/28/2024.” Medical record review did not include psycho-social assessment of family coping mechanism, adjustment or lack of adjustment to terminal illness. The hospice failed to make available, counseling services to family/caregiver to minimize stress associated with caring for terminally-ill.”

“Based on record review and interview with the Administrator/ Director of Patient Services, the Hospice failed to ensure that counseling and bereavement services were made available to the family and other individuals in the bereavement plan of care for up to one year following the death of the patient, and to ensure that bereavement services reflect the needs of the bereaved. This was evident for two (2) of fourteen (14) clinical records reviewed (Patients # 11 and #12). Failure to ensure counseling and bereavement services are made available and reflect the needs of the bereaved has the potential for negative outcomes. The findings are: 1) Patient #1 has a start of care date of 7/18/2023 and an expiration date of 8/6/2023. The” Bereavement On Call/ Unscheduled Visit” dated 8/7/2023 documents:” Bereavement services. Bereavement recommendations. Services Patient caregiver is interested in receiving mailings, telephone calls. Staff is offering mailings, support groups, adult loss of a parent support group. Summary of findings/ Impression. Score is based on agency standards: Low Risk”. The “; Charts/ Clinical Notes” dated 10/27/2023 document:” Social Worker called son to introduce self and monthly bereavement support. He was appreciative of the call. He stated he was a bit busy and noted that he is doing okay, keeping busy. He stated that he and his sister miss their mother and are grateful for the time they had and are glad that she is now in peace. Social Worker extended empathic listening and offered support, validated his efforts and commitment toward his mothers care and accepting the ups and downs of his grieving process. He is receptive to monthly calls for bereavement support”. The “;Charts/ Clinical Notes” dated 10/30/2023 document:” Writer mailed out letter for 3 months bereavement support”. On 5/8/2024 at 11:35 AM, The surveyor requested the Bereavement policy. The Hospice provided a policy with no effective and no revision date. The policy document the following:” Within two weeks of a patient death, a condolence card will be mailed to the family. Within a month of a twelve month bereavement- mailing program will be initiated for designated family members”. There is no documented evidence of a condolence card being mailed to the family. There is no documented evidence of twelve month bereavement mailing program being initiated by the Hospice. 2) Patient #12 has a start of care date of 11/2/2023 and an expiration date of 11/27/ 2023. There is no documented evidence of a bereavement assessment into the comprehensive assessment. There is no documented evidence of a bereavement Plan of Care. There is no documented evidence of ongoing bereavement assessments. There is no documented evidence of bereavement support and counseling to the family after the patients death. On 5/9/2024 at 4:00PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on record review and staff interview, the Hospice failed to ensure that volunteers are used in day-to-day administrative and/or direct patient care roles. This was evident for eight (8) of fourteen (14) clinical records reviewed (Patients #1, #6, #8, # 9, #11, #12, #13, and #14). Failure to ensure that volunteers are used in day-to-day administrative and/or direct patient care role has the potential for negative outcomes. The findings are: 6) Patient #11 has a start of care date of 7/18/2023 and an expiration date of 8/6/2023 with diagnoses of Cerebral Atherosclerosis Pulmonary Embolism and Gastrointestinal Hemorrhage as documented on the “;Physicians Orders/ Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023. Physicians Orders/ Plan of Care” for the Certification Period of 7/18/2023 to 10/15/2023 documents:” Treatments: Skilled Nursing. Medical Social Worker 1-4 x a month for 4 months”. The “;Hospice Initial Visit Comprehensive” dated 7/18/2023conducted by a Registered Nurse lacks documented evidence of volunteers services offered. The “Social Worker Initial Visit “;dated 7/20/2023 lacks documented evidence of an evaluation for volunteers services. There is no documented evidence of volunteers services offered or the use of volunteer services provided in the Plan of Care. 7) Patient #12 has a start of care date of 11/2/2023 and an expiration date of 11/27/2023 with diagnoses that include Cancer of the Lung, Secondary Malignant Neoplasm of the Bone as documented on the “; Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 1/30/2024. The “;Physicians Orders/ Plan of Care” for the Certification Period of 11/2/2023 to 1/30/2024 documents:” Skilled Nursing 1-2 x week for 12 weeks. Medical Social Worker 1-2x month for 3 months. Aide 1-2x week for one week, 3-5x week for 11 weeks Spiritual Care 1-2 x months x 3 months. The “;Hospice Initial Visit Comprehensive” 11/2/2023 conducted by a Registered Nurse lacks documented evidence volunteers’ services offered. The Social Worker Initial Visit “; dated 11/7/2023 lacks documented evidence of an evaluation for volunteers services. There is no documented evidence of volunteers services offered, or the use of volunteer services provided in the Plan of Care. 8) Patient #13 has a start of care date of 8/24/2023 and a discharge date of 11/17/2023 with diagnoses that include Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Cardiogenic Shock, Pulmonary Hypertension as documented on the” Physicians Orders / Plan of Care” for the Certification Period of 8/24/2023 to 11/21/2023. The” Physicians Orders / Plan of Care” for the Certification Period of 8/24/2023 to 11/21/2023 documents:” Skilled Nurse 1-2 times a week for 13 weeks. Medical Social Worker 1-4x month for 4 months. The “;Hospice Initial Visit Comprehensive” 8/24/2023 conducted by a Registered Nurse lacks documented evidence of volunteers services offered. The Social Worker Initial Visit “;dated 8/28/2023 lacks documented evidence of an evaluation for volunteers services. There is no documented evidence of volunteers services offered or the use of volunteer services provided in the Plan of Care. On 5/9/2024 at3:45 PM, the Administrator was interviewed and did not provide an explanation for the findings. 4) Patient # 6 has a Start Of Care date of 3/12/2024 with diagnosis of “Thyrotoxicosis with diffuse goiter without Thyrotoxic crisis or storm, Hypothyroidism unspecified, Unspecified Dementia-unspecified severity without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 1 to 2 times per month for 4 months”. The “Social Work Initial Visit” note dated “03-14-2024” lacks documented evidence Volunteer services were offered. The Plan of Care lacks documented evidence of an order for Volunteer services. The clinical record lacks documentation the patient was assessed for the need of Volunteer services. The Hospice failed to meet the Hospice patient Palliative needs. 5) Patient # 9 has Start Of Care date of 1/4/2024 with a diagnosis of “Alzheimer’s Disease-unspecified” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “01-04-24 to 03-03-24”. The Hospice “Physician’s Orders/Plan of Care” dated “01-04-24 to 03-03-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks, MSS (Medical Social Services) 1 to 3 times per month for 3 months, SC (Spiritual Counselor) 1 to 3 times per month for 3 months”. The “Social Work Initial Visit” note dated “01-12-2024” lacks documented evidence Volunteer services were offered. The Plan of Care lacks documented evidence of an order for Volunteer services. The clinical record lacks documentation the patient was assessed for the need of Volunteer services. The Hospice failed to meet the Hospice patient Palliative needs. On 5/9/2024 at 3:50pm findings and interview was conducted with the Administrator, no additional information received. 1) Patient #1 has a start of care date of 1/9/2024 with diagnoses of Advanced Dementia, Weight Loss as documented on the “Orders / Plan of Care” for the Certification Period of 3/9/2024-5/7/2024. The “Orders / Plan of Care” for the Certification Period of 3/9/2024-5/7/2024 documents:” Skilled Nurse 1-2 times a week x 9weeks, Medical Social Worker 1-2x month for 3 months, Spiritual Counselling , 1-2xmonth x 3months. The “Hospice Initial Visit Comprehensive assessment” conducted by a Registered Nurse on 1/9/2024 lacks documented evidence of volunteers services offered. The Social Worker Initial Visit “;dated 1/17/2024 lacks documented evidence of an evaluation for volunteers services There is no documented evidence of volunteers services offered or the use of volunteer services provided in the Plan of Care, progress notes, or case conference summary reports. On 5/9/2024 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings. 2) Patient #8 has a start of care date of 3/6/2024 with diagnoses of Myeloproliferative Disorder, Advanced Dementia as documented on the “Orders/Plan of Care” for the certification period of 3/6/2024-6/3/2024. The “Orders / Plan of Care” for the Certification Period of 3/6/2024-6/3/2024 documents:” Skilled Nurse 2-3 times a week x 14weeks, Medical Social Worker 1-2x month for 4 months, Spiritual Counselling , 1-2xmonth x 4months. The “;Hospice Initial Visit Comprehensive assessment” dated 3/6/2024 conducted by a Registered Nurse lacks documented evidence of volunteers services offered. The Social Worker Initial Visit “;dated 3/11/2024 lacks documented evidence of an evaluation for volunteers services There is no documented evidence of volunteers services offered or the use of volunteer services provided in the Plan of Care, progress notes, case conference summary reports. On 5/9/2024 at 3:10 PM, the Administrator was interviewed and did not provide an explanation for the findings. 3) Patient #14 has a start of care date of 11/30/2023 with diagnoses of cerebral atherosclerosis, cancerous lesion , right upper arm, weight loss and spinal stenosis as documented on the “Orders/Plan of Care, 1/29/2024-3/28/2024” The “Orders/Plan of Care “ for the certification period of 1/29/2024-3/28/2024 documented skilled nurse 1-2xweekx9weeks; Medical Social worker, 1xmonthx1month; Spiritual Counseling, 1xmonthx1month. The “Hospice Initial Visit Assessment” conducted by Registered Nurse on 11/30/2023 lacked documented evidence of volunteer services offered. The Social Worker initial visit on 12/5/2023 lacked documented evidence of an evaluation for volunteer services. There is no documented evidence of volunteers services offered or the use of volunteer services provided in the Plan of Care, progress notes or case conference summary reports. On 5/9/2024 at 3:20 PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on record review and staff interview, the Hospice failed to ensure each patient records contain the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes. This was evident for two (2) of fourteen (14) clinical records reviewed (Patients #2 and #10). Failure to ensure each patient records contain the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes has the potential for negative outcomes. The findings are: 1) Patient # 2 has a Start of Care date of 11/10/2023 with diagnosis of Malignant Neoplasm of female Breast with Metastasis to Bone, Schizophrenia, Depression, Type 2 Diabetes, Hyperlipidemia as documented on the Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24”. The Hospice “Physician’s Orders/Plan of Care” dated “02-08-24 to 05-07-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 3 times per month for 4 months and Aide 1 to 3 times per week for 1 week, 1 to 5 time per week for 12 weeks”. The record lacked document evidence of an updated comprehensive assessment for certification period “;02-08-24 to 05-07-24”. “;Routine visit” dated 02/08/2024 lacked document evidence of a complete comprehensive assessment. 2) Patient # 10 has a Start of Care date of 09/05/2023 with diagnosis of Cerebral Atherosclerosis, Hypertension, Chronic Kidney Disease, Hyperlipemia and Unspecified Gout as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks,1 times per week for 1 week, MSS (Medical Social Services) 1 to 2 times per month for 3 months, SC (Spiritual Counselor) 1 to 2 times per month for 3 months and Aide 1 to 2 times per week for 1 week, 1 to 5 time per week for 8 weeks and 1 to 2 times per week times one week”. The record lacked document evidence of an updated comprehensive assessment for certification period “;03-08-24 to 05-06-24”. “;Routine visit” dated 03/06/2024 lacked document evidence of a complete comprehensive assessment. On 5/9/2024 at 3:30pm findings reviewed with the Administrator and Clinical Manager; no addition information provided.”

“Based on record review and staff interview, the Hospice failed to ensure that for each patient that revokes the election of hospice care or is discharged from hospice care, the hospice forwards a copy of the discharge summary and if requested, the patients clinical record, to the attending physician. This was evident for two (2) of two (2) discharged clinical records reviewed (Patients #13 and #14). Failure to ensure that for each patient that revokes the election of hospice care or is discharged from hospice care, the hospice forwards a copy of the discharge summary and if requested, the patients clinical record, to the attending physician has the potential for negative outcomes. The findings are: 2) Patient # 14 has a start of care date of 11/30/2023 with the diagnoses including Cerebral Atherosclerosis, Cancerous Lesion Right Upper Arm, Weight Loss, and Spinal Stenosis as documented on the “Orders/Plan of Care benefit period , 1/29/2024-3/28/2024.” On 3/28/2024, the patient was discharged from the hospice. The Hospice “ Notice of Medicare Non-Coverage” form informing patient and responsible family member of effective date current hospice service will end was dated 3/28/2024.The “Notice of Medicare Non- Coverage” form did not have signature of patient or family member. There is no documentation that indicates the “Notice of Medicare Non-Coverage” form was delivered to next-of-kin and patient at least two-calendar days before Medicare covered services ends. Social worker’s notes of 3/8/2024 indicated social worker attempted to reach patient’s family member via telephone and was informed by patient’s friend the patient’s next-of -kin is hospitalized. There is no documentation that patient’s interdisciplinary care team proposing an alternate level of care while next-of-kin is hospitalized. There is no documented evidence of the signed statement of the patient revoking the election of the Medicare coverage of Hospice for the remainder of that election period. There is no documentation of the hospice physician rescinding the patients terminal diagnosis if the patient is no longer eligible for hospice care. The hospice failed to determine that the patient was no longer terminally ill, hold an Interdisciplinary case conference with patient, patient’s physician, and next-of-kin to discuss a safe patient discharge and alternate level of care, consult with patient’s attending physician prior to discharging the patient, or obtain an order from the hospice physician to discharge the patient. On 5/9/2024 at 3:00PM, the findings were reviewed with the Administrator/ Director of patient services, Clinical Nurse Manager. They acknowledged the findings and provided no additional information. 1) Patient #13 has a start of care date of 8/24/2023 and a discharge date of 11/17/2023. On 5/7/2024 at 11:30 AM, the surveyor requested the discharge summary of the patient. The Hospice submitted a Notice of Medicare Non Coverage dated 11/17/2023 that document:” Social Worker emailed Notice of Medicare non coverage to patients son and phone to confirm receipt and understands the content of the notice and also the appeal process. They also understand that patient can be referred to Hospice again if there is a decline in patients condition. The Hospice submitted a “;Discharge Summary as of 5/7/2024” without the name or signature person completing the discharge summary. There is no documented evidence of the signed statement of the patient revoking the election of the Medicare coverage of Hospice for the remainder of that election period. There is no documentation of the hospice physician rescinding the patients terminal diagnosis if the patient is no longer eligible for hospice care. There is no documented evidence of post discharge continuity of care. There is no documented evidence the discharge summary to the patients attending physician. On 5/9/2024, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on clinical record review, agency policy and procedure, and staff interview, the hospice failed to ensure a comprehensive discharge and transfer summary was prepared as required. This was evident in two (2) of fourteen (14) patient records reviewed (Patients #10 and #14). Failure to prepare a comprehensive discharge/transfer summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge/transfer from the hospice. The findings are: 2) Patient # 14 has a start of care date of 11/30/2023. The diagnoses included, Cerebral Atherosclerosis, Cancerous Lesion Right Upper Arm, Weight Loss, and Spinal Stenosis as documented on the “Orders/Plan of Care with benefit period, 1/29/2024-3/28/2024.” On 3/28/2024, the patient was discharged from the hospice. The “;Orders / Plan of Care” for the Certification Period of 1/29/2024- 3/28/2024 documents:” Skilled Nurse 1-2 times a week x 9 weeks. Medical Social Worker, 1xmonth x 1-month, Spiritual Counseling 1xmoth x 1 month. The patient’s clinical record lacked documented evidence of any communication with patients physician and next-of-kin. The record lacked discharge planning and discharge summary. There is no documented evidence that a comprehensive summary of patients care, treatment while in hospice was sent to patient’s physician. The clinical record lacked evidence of a discharge order from the hospice physician. On 5/9/2024 at 12: 00.PM, surveyor requested discharge summary, and all related communication between hospice, patient’ next-of-kin and physician. The surveyor was handed the “Notice of Medicare Non-Coverage Form” with a note sticker that read “discharge related documentation” on 5/10/2024 at 11:00. AM. The findings were reviewed with hospice leadership on 5/10/2024 during the exit conference. 1) Patient # 10 has a Start of Care date of 09/05/2023 with diagnosis of Cerebral Atherosclerosis, Hypertension, Chronic Kidney Disease, Hyperlipemia and Unspecified Gout as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-08-24 to 05-06-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 9 weeks,1 times per week for 1 week, MSS (Medical Social Services) 1 to 2 times per month for 3 months, SC (Spiritual Counselor) 1 to 2 times per month for 3 months and Aide 1 to 2 times per week for 1 week, 1 to 5 time per week for 8 weeks and 1 to 2 times per week times one week”. Physician Note dated 01/11/2024 documents “;patient was discharge from hospice recently due to hospitalization for acute abdomen from strangulated hernia requiring surgery”. On 5/08/2024 at 3.30 PM, the surveyor requested the discharge/transfer summary of the patient, any communication between agency or Register Nurse notification of Physician, notes related to dates patient was hospitalized. There is no documented evidence the discharge summary to the patients attending physician. The record lacked document evidence of transfer/discharge summary. On 5/9/2024 at 3:30pm findings reviewed with the Administrator and Clinical Manager; no addition information provided.”

“Based on clinical record review, review of the agency’s policy and procedure and staff interview, the hospice failed to ensure patient and family representative received a copy of policy/procedure on management and disposal of controlled drugs at the time the controlled medications were ordered. This was evident in one (1) of fourteen (14) clinical records reviewed (Patient # 1). Failure to ensure patient and family representative received a copy of policy/procedure on management and disposal of controlled drugs has the potential to jeopardize safe use and disposal of control drugs and the potential for negative patient outcomes. The findings are: Patient # 1 has a start of care date of 1/9/2024 with diagnoses including Advanced Dementia, Weight Loss as documented on the “Orders/Plan of Care from 3/9/2024 to 5/7/2024. The physician order/ medication profile documented :Morphine Sulfate Powder RDT tablet, one tablet as needed every four hours sublingual (under the tongue) as needed for pain, Lorazepam by mouth, tablet 0.5MG one tablet as needed every four hours by mouth for agitation. The clinical record lacks documented evidence the patient or family received a copy of the hospice’s written policy on management and disposal of controlled drugs, education on use and side effects to report . The findings were reviewed with hospice Clinical Manager, Administrator, and Vice President on 5/8/2024 at 3:00.PM. No explanation was provided.”

“Based on record review and staff interview, the Hospice failed to ensure each patient or their representative and the family are educated regarding the safe use and disposal of controlled drugs. This was evident for one (1) of fourteen (14) clinical records reviewed (Patient #1). Failure to ensure each patient or their representative and the family are educated regarding the safe use and disposal of controlled drugs has the potential for negative outcomes. The findings are: Patient # 1 has a start of care date of 1/9/2024 with diagnoses including Advanced Dementia, Weight Loss as documented on the “Orders/Plan of Care from 3/9/2024 to 5/7/2024. The physician order/ medication profile documented :Morphine Sulfate Powder RDT tablet, one tablet as needed every four hours sublingual (under the tongue) as needed for pain, Lorazepam by mouth, tablet 0.5MG one tablet as needed every four hours by mouth for agitation. The clinical record lacks documented evidence the patient or family received a copy of the hospice’s written policy on management and disposal of controlled drugs, education on use and side effects to report . The findings were reviewed with hospice Clinical Manager, Administrator, and Vice President on 5/8/2024 at 3:00.PM. No explanation was provided.”

“Based on clinical record review, review of the agency’s policy and procedure and staff interview, the hospice failed to document in the patients clinical record that the written policies and procedures for managing controlled drugs was provided and discussed. This was evident in one (1) of fourteen (14) clinical records reviewed (Patient # 1). Failure to document in the patients clinical record that the written policies and procedures for managing controlled drugs was provided and discussed has the potential for negative patient outcomes. The findings are: Patient # 1 has a start of care date of 1/9/2024 with diagnoses including Advanced Dementia, Weight Loss as documented on the “Orders/Plan of Care from 3/9/2024 to 5/7/2024. The physician order/ medication profile documented: Morphine Sulfate Powder RDT tablet, one tablet as needed every four hours sublingual (under the tongue) as needed for pain, Lorazepam by mouth, tablet 0.5MG one tablet as needed every four hours by mouth for agitation. The clinical record lacks documented evidence the patient or family received a copy of the hospice’s written policy on management and disposal of controlled drugs, education on use and side effects to report. The findings were reviewed with hospice Clinical Manager, Administrator, and Vice President on 5/8/2024 at 3:00PM. No explanation was provided.”

“Based on record review and staff interview, the Hospice failed to ensure the skilled nursing facility (SNF) immediately notifies the hospice of a significant change in the patients physical, mental, social, or emotional status occurs or if clinical complications appear that suggest a need to alter the plan of care. This was evident for two (2) of fourteen (14) clinical records reviewed (Patients #6 and #7). Failure to ensure the skilled nursing facility (SNF) immediately notifies the hospice of a significant change in the patients physical, mental, social, or emotional status occurs or if clinical complications appear that suggest a need to alter the plan of care has the potential for negative outcomes. The findings are: 1) Patient # 6 has a Start Of Care date of 3/12/2024 with diagnosis of “Thyrotoxicosis with diffuse goiter without Thyrotoxic crisis or storm, Hypothyroidism unspecified, Unspecified Dementia-unspecified severity without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24”. The Hospice “Physician’s Orders/Plan of Care” dated “03-12-24 to 06-09-24” documents orders for “SN (Skilled Nurse) 1 to 2 times per week for 13 weeks, MSS (Medical Social Services) 1 to 2 times per month for 4 months, SC (Spiritual Counselor) 1 to 2 times per month for 4 months”. The clinical record lacks documented evidence of arrangements and responsibility with the Skilled Nursing Facility related to the Hospice patient continuous care. The Hospice failed to meet the Hospice patient Palliative needs. 2) Patient # 7 has a Start Of Care date of 1/31/2024 with diagnosis of “Malignant Neoplasm of Bladder-Unspecified” as documented on the Hospice “Physician’s Orders/Plan of Care” dated “01-31-24 to 04-29-24”. The Hospice “Physician’s Orders/Plan of Care” dated “01-31-24 to 04-29-24” documents orders for “SN (Skilled Nurse) 1 time a week for 14 weeks, MSS (Medical Social Services) 1 time a month for 1 month”. The clinical record lacks documented evidence of arrangements and responsibility with the Skilled Nursing Facility related to the Hospice patient continuous care. The clinical record lacks documented evidence of a current Plan of Care. The Hospice failed to meet the Hospice patient current Palliative needs. On 5/9/2024 at 3:50pm findings and interview was conducted with the Administrator, no additional information received.”