Putnam County Hospice

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed of patients that elected hospice aide services it was revealed that the agency did not ensure the registered nurse (RN) provided the aide with clear and accurate patient-specific written care instructions. CONTINUATION OF REQUIRED ACTION Clinical Record 2: The aide care plan dated 08/02/2024 ordered two (2) bathing tasks: “Bed Bath (as needed if too weak for showering)” and “Shower bath”. The RN did not ensure the aide was provided a clear and specific bathing order based on the RN’s assessment of the patient’s medical needs. The aide visit note dated 08/09/2024 reported the task “Shower bath” was performed. The Administrator, Clinical Manager, and Business Office Manager stated in an interview on 08/15/2024 that the agency did not ensure that the RN provided the aide with clear and accurate patient-specific written care instructions for the task “Bathing”. CONTINUATION OF REQUIRED ACTION”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed of patients that elected hospice aide services and required the aide to report changes in the patient’s medical status to the registered nurse (RN) it was revealed that the agency did not ensure the aide reported changes in the patient’s medical needs to the RN as the changes related to the aide care plan. Clinical Record 1: The aide care plan dated 07/23/2024 ordered the tasks “Transfer and/or Ambulate patient with Rollator Walker”, “Use Shower Chair for shower bath”, “Apply Lotion to Skin”, and “Apply Powder to Skin” at every visit. The aide visit note dated 07/26/2024 reported the patient refused the tasks “Transfer and/or Ambulate patient with Rollator Walker” and “Use Shower Chair for shower bath”. The record lacked evidence that the aide reported to the RN the change in the patient’s medical condition as it related to the patient refusing the ordered tasks. The aide visit note dated 08/09/2024 reported the patient refused the tasks “Apply Lotion to Skin” and “Apply Powder to Skin”. The record lacked evidence that the aide reported to the RN the change in the patient’s medical condition as it related to the patient refusing the ordered tasks. Clinical Record 2: The aide care plan dated 08/02/2024 ordered the tasks “Shampoo Hair” and “Apply Powder to Skin”. The aide visit note dated 08/09/2024 reported the patient refused the tasks “Shampoo Hair” and “Apply Powder to Skin”. The record lacked evidence that the aide reported to the RN the change in the patient’s medical condition as it related to the patient refusing the ordered tasks. Clinical Record 4: The aide care plan dated 08/01/2024 ordered the tasks “Shampoo Hair”. The aide visit note dated 08/09/2024 reported the patient refused the task “Shampoo Hair”. The record lacked evidence that the aide reported to the RN the change in the patient’s medical condition as it related to the patient refusing the ordered task. The Administrator, Clinical Manager, and Business Office Manager stated in an interview on 08/15/2024 that the agency did not ensure the aide reported changes in the patient’s medical needs to the RN as the changes related to the aide care plan.”

“It is required that the hospice must conduct and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records, document review and interviews which revealed the hospice: Failed to ensure that a comprehensive assessment was completed within 5 days of election of hospice [HCPC.9. I/L523]; Failed to ensure that each patient’s comprehensive assessment identified the spiritual needs related to the terminal illness [HCPC.10. I/L524]; and Failed to ensure that the drug profile contained complete accurate information [HCPC.15. I/L530]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.54: Initial and comprehensive assessment of the patient. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure that the registered nurse member of the IDG ensured the implementation of the IDG plan of care [HCPC.19. I/L540]; Failed to ensure that the plan of care included a detailed statement related to the scope and frequency of services for each discipline [HCPC.21. I/L547]; and Failed to ensure that all required medical supplies were included in the plan of care [HCPC.21. I/L550]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review, personnel record review and interview which revealed the hospice: Failed to ensure that education related to the hospice philosophy was included in orientation [HSRM.15. I/L661] and failed to ensure that a skills check competency was completed on all individuals [HSRM.14. I/L663]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.100, Organization and Administration of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice has a clinical record containing past and current findings and is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review, personnel record review and interview which revealed the hospice: Failed to ensure that the plan of care included appropriate orders for all identified needs [HSIM.3. I/L678]; Failed to ensure that a discharge summary was completed and forwarded to the Medicare facility after the live discharge [HCDT.38. I/L682]; Failed to ensure that a discharge summary was sent to the patient’s attending physician after the patient’s revocation from hospice care [HCDT.39.I/L683]: and Failed to ensure that a discharge summary was completed that contained all required elements [HCDT.40. I/L6844]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care for the condition of participation CFR 418.104, Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. This standard was not met as evidenced by document review and interview. Review of the agency Emergency Preparedness plan revealed that the agency did not ensure that the plan was reviewed and updated at lease every two years. Document 3: Emergency preparedness plan and all hazards risk assessment was documented as reviewed in 2021. There was no other documentation of any reviews or updates. In interview on 06/27/2024, Director of Nursing reported that the emergency preparedness plan was reviewed by the county every five years and confirmed that the agency had not reviewed the plan since 2021. The agency did not ensure that the emergency preparedness plan was reviewed and updated every two years.”

“It is required that the hospice EP training program includes the following for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by personnel record review and interview. In 11 of 11 (100%) personnel records reviewed it was revealed that the agency did not ensure that all hospice staff were trained on emergency preparedness upon hire and at least every 2 years. Personnel Record 1: The registered nurse was hired 02/12/2024. There was no evidence of Emergency and Disaster Preparedness training upon hire. Personnel Record 2: The registered nurse was hired 06/19/2017. There was no documentation of emergency preparedness training since 2021. Personnel Record 3: The aide was hired 07/11/2011. There was no evidence of emergency and disaster preparedness training and education for the years 2021, 2022, and 2023, and 2024 to date. Personnel Record 4: The date of hire was 09/19/2022. There was no evidence of emergency preparedness training at hire or for the years 2023, and 2024 to date. Personnel Record 5: The date of hire was 12/19/2022. There was no evidence of emergency and disaster training upon hire or for the years 2023, and 2024 to date. Personnel Record 6: The date of hire was 05/01/2023. There was no evidence of emergency preparedness training at hire and to date. Personnel Record 7: The date of hire was 09/19/2022. There was no evidence of emergency disaster preparedness at hire or for the years 2023 and 2024 to date. Personnel Record 8: The Medical Director was hired 07/01/2013. There was no evidence of emergency preparedness training for 2021, 2022, 2023, and 2024 to date. Personnel Record 9: The Volunteer Coordinator was hired 03/18/2024. There was no evidence of emergency preparedness training to date. Personnel Record 10: The volunteer was hired 07/31/2017. There was no evidence of emergency preparedness training for the years 2021, 2022, 2023, and 2024 to date. Personnel Record 11: The Massage therapy contract was dated 07/30/2015. There was no documentation of emergency preparedness training for the years 2021, 2022, 2023, and 2024 to date. In interview on 06/28/2024, Director of Nursing stated, “I think we just do the drills.””

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives, and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by interview and personnel record review. In 5 of 5 (100%) applicable personnel records reviewed it was revealed that the agency did not ensure that the initial orientation provided education related to the agency policy and procedures related to advanced directives. Personnel Record 1: The employee was hired 02/12/2024. There was no evidence of training or orientation related to advanced directives or the organization’s policies related to advanced directives. Personnel Record 5: The employee was hired 12/19/2022. There was no evidence of training or orientation related to advanced directives or the organization’s policies related to advanced directives. Personnel Record 6: The employee was hired 05/01/2023. There was no evidence of training or orientation related to advanced directives or the organization’s policies related to advanced directives. Personnel Record 7: The employee was hired 09/19/2022. There was no evidence of training or orientation related to advanced directives or the organization’s policies related to advanced directives. Personnel Record 9: The employee was hired 03/18/2024. There was no evidence of training or orientation related to advanced directives or the organization’s policies related to advanced directives. The Director of Nursing confirmed in interview on 06/28/2024 that the agency did not include advanced directives education upon hire.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed it was revealed that the agency did not ensure that a comprehensive assessment was completed within 5 days of election of hospice. Clinical Record 17: The initial assessment was completed on 04/27/2024. The social work assessment was initiated over the phone on 05/06/2024 with a note stating the emotional and social functioning would be discussed more with the patient and family at an in-person visit. There was no spiritual care assessment completed. There was no documentation to explain why social work assessment was not completed in person within 5 days of start of care or why there was no documented spiritual care assessment. The Director of Nursing reviewed the clinical record on 06/26/2024 and confirmed that the comprehensive assessment was not completed within 5 days and that the clinical record did not contain missed visit notes or documentation to explain the delay.”

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 9 of 19 (48%) clinical records reviewed it was revealed that the agency did not ensure that each patient’s comprehensive assessment identified the spiritual needs related to the terminal illness. Clinical Record 4: The spiritual assessment was blank on the skilled nurse (SN) initial assessment completed on 05/20/24. The social work (SW) assessment sections of Emotional Distress, spiritual concerns, and end-of-life issues in the EMR were left blank. The SW assessment included a note that the patient was stable with social/emotional functioning but did not address spirituality. There was no spiritual assessment documented in the clinical record. The Plan of Care indicated that spiritual counseling was declined as the reason for no visit frequency, but the record did not indicate who, when, or why spiritual care was declined. Clinical Record 6: The SN and SW completed a comprehensive assessment together on 06/04/2024. The spiritual assessment section of the nursing assessment was left blank. The social work assessment sections related to spiritual concerns and spiritual needs were left blank. There was no evidence of a spiritual assessment in the clinical record. Clinical Record 10: The SN assessment completed on 01/03/2024 did not include a spiritual assessment. The social work assessment completed on 01/05/2024 did not include the spiritual assessment components. There was no documentation of a spiritual assessment. Clinical Record 12: The SN assessment was completed upon admission on 04/18/2024 but did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 04/23/2024 did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. Clinical Record 13: The SN assessment completed on 06/15/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR left blank. Spiritual concerns on the SW assessment completed on 06/18/20124 were left blank. Clinical Record 15: The initial assessment completed on 02/28/2024 did not include a spiritual care component. The spiritual assessment section in the RN assessment was left blank. The social worker completed a social work assessment on 02/28/2024 but did not address the spiritual assessment. Clinical Record 16: The initial assessment completed on 03/21/2024 did not include a spiritual care component. The spiritual assessment section in the RN assessment was left blank. The social worker completed a social work assessment at the same time as the nurse on 03/21/2024 but did not address the spiritual assessment. Clinical Record 17: The initial assessment completed on admission on 04/27/2024 but did not include a spiritual assessment. Spiritual assessment questions in EMR left blank. The social work assessment completed on 05/06/2024 via phone did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. Clinical Record 19: The initial assessment completed on 05/06/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 05/07/2024 did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. The director of nursing stated in an interview on 06/26/2024, “I didn’t know they had to have a spiritual assessment.””

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed it was revealed that the agency did not ensure that the drug profile contained complete accurate information. Clinical Record 1: The skilled nurse assessment dated 05/29/2024 revealed that the patient had a port placed in her left chest wall. The plan of care interventions read, “Access port 1 x month and PRN to flush.” The plan of care did not include specific directions instructing what to flush the port with. There were no solutions on the medication profile indicating port flush solution. An order was written 06/21/2024 to flush the port monthly with 20ml of saline to maintain patency. Clinical Record 4: The skilled nurse initial assessment dated 05/20/2024 revealed that the patient was short of breath and required oxygen via nasal cannula from 3-8L/min. The plan of care and medication profile created 05/20/2024 included “oxygen” but did not include dose, frequency route, or duration. The director of Nursing confirmed in an interview on 06/27/2024 that the orders were incomplete.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by record review and interview. In 11 of 19 (58%) records reviewed it was revealed that the agency did not ensure the registered nurse member of the IDG ensured the implementation of the IDG plan of care. Clinical Record 4: The spiritual care section of the skilled nurse assessment dated 05/20/2024 was blank. The spiritual care concerns section on the social work assessment also dated 05/20/2024 was blank. The comprehensive assessment did not contain a spiritual assessment, or documented details related to the patient refusal. Clinical Record 6: The skilled nurse and social worker completed the comprehensive assessment during a joint visit on 06/04/2024. The spiritual assessment section of the nursing assessment was left blank. The social work assessment sections related to spiritual concerns and spiritual needs was left blank. There was no documentation in the assessments to report that the patient refused the spiritual assessment. Clinical Record 10: The skilled nurse assessment completed 01/03/2024 did not include a spiritual assessment. The social work assessment completed on 01/05/2024 did not include any spiritual assessment components. The record did not include documentation to explain why there was no spiritual assessment or that the patient refused. Clinical Record 11: The skilled nurse assessment completed on 01/03/2024 revealed that the patient was tearful but the spiritual assessment within the nursing assessment was blank. The Spiritual Perspective section of the social work assessment completed on 01/05/2024 was left blank. The social work assessment summary revealed that the patient used to attend a non-denomination church. There was no further documentation in the clinical record to address why a spiritual care assessment was not completed. There was no documentation to explain that the patient refused the spiritual assessment and care. Clinical Record 12: The skilled nurse assessment was completed on 04/18/2024 and did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 04/23/2024 did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 13: The skilled nurse assessment completed on 06/15/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were blank. The Spiritual concerns section of the social worker assessment completed 06/18/20124 were left blank. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 14: The skilled nurse assessment completed on 06/18/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 06/18/2024 did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 15: The initial assessment completed on 02/28/2024 did not include a spiritual care assessment. The EMR had a spiritual assessment section in the RN assessment that was left blank. The social worker completed a social work assessment at the same time as the nurse on 02/28/2024 but did not address the spiritual assessment. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 16: The initial assessment completed on 03/21/2024 did not include a spiritual care component. The EMR had a spiritual assessment section in the RN assessment that was left blank. The social worker completed a social work assessment at the same time as the nurse on 03/21/2024 but did not address the spiritual assessment. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 17: The skilled nurse assessment completed on 04/27/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 05/06/2024 via phone did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. The clinical record contained no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 19: The skilled nurse assessment completed on 05/06/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 05/07/2024 did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. The director of nursing stated in an interview on 06/26/2024, “Oh, I didn’t know we had to do a spiritual assessment, we just ask them if they want it, and if they say they have their own priest or whatever we don’t do it.””

“It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) records reviewed it was revealed that the agency did not ensure that the plan of care included a detailed statement related to the scope and frequency of services for each discipline. Clinical Record 2: The Plan of Care for the certification period 05/31/2024 - 07/29/2024 included orders for discipline and treatments section included “Services accepted RN, Aide, Spiritual and Medical Social Worker (MSW).” The plan of care did not contain orders for frequency or duration for spiritual care or social work. The clinical record contained documentation of a visit for spiritual care performed on 05/31/2024 with no order. The Director of Nursing reviewed documentation on 06/25/2024 and verified that there were no orders for the current certification period for MSW or Spiritual Care services.”

“It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed it was revealed that the agency did not ensure that all required medical supplies were included in the plan of care. Clinical Record 2: The patient’s plan of care for the episode 05/31/2023 - 07/29/2024 included the diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, other obstructive and reflux uropathy, encounter for fitting and adjustment of urinary device, unspecific hydronephrosis. The comprehensive nursing assessment dated 04/01/2024 and the skilled nurse (SN) visit note dated 05/30/2024 documented that the patient had a Foley catheter in place. The plan of care dated 05/31/2024 -07/29/2024 did not include Foley catheter supplies. During the home visit completed on 06/27/2024, it was confirmed that patient had a Foley catheter in place. Clinical Record 6: The skilled nurse assessment and plan of care dated 06/04/2024 revealed that the patient had an ulcer on the right heel that required wound care and an indwelling foley catheter. The plan of care did not include foley supplies and wound care supplies. On 06/25/2024, the director of nursing reviewed the clinical records and confirmed that the plans of care did not include the required elements for the foley catheter or wounds.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by clinical record review and interview. In 11 of 19 (58%) clinical records reviewed it was revealed that the agency did not ensure that the agency provided an assessment of the patient and family’s spiritual needs and or documented the refusal of services. Document 5: Agency policy No. 4-005.1 titled, Spiritual Care Counseling services”, updated April 2021 read in part, “8. Spiritual care assessments and counseling will be documented in the patient’s chart as part of the comprehensive assessment. 9. If the patient and family/caregiver refuse spiritual care services, the medical social worker will document the refusal. The interdisciplinary group members will make continued inquiries. 10. Ongoing comprehensive assessments will be made by interdisciplinary group members to identify any developing spiritual needs.” Clinical Record 4: The spiritual care section of the skilled nurse assessment dated 05/20/2024 was blank. The spiritual care concerns section on the social work assessment also dated 05/20/2024 was blank. The comprehensive assessment did not contain a spiritual assessment, or documented details related to the patient refusal. Clinical Record 6: The skilled nurse and social worker completed the comprehensive assessment during a joint visit on 06/04/2024. The spiritual assessment section of the nursing assessment was left blank. The social work assessment sections related to spiritual concerns and spiritual needs was left blank. There was no documentation in the assessments to report that the patient refused the spiritual assessment. Clinical Record 10: The skilled nurse assessment completed 01/03/2024 did not include a spiritual assessment. The social work assessment completed on 01/05/2024 did not include any spiritual assessment components. The record did not include documentation to explain why there was no spiritual assessment or that the patient refused. Clinical Record 11: The skilled nurse assessment completed on 01/03/2024 revealed that the patient was tearful but the spiritual assessment within the nursing assessment was blank. The Spiritual Perspective section of the social work assessment completed on 01/05/2024 was left blank. The social work assessment summary revealed that the patient used to attend a non-denomination church. There was no further documentation in the clinical record to address why a spiritual care assessment was not completed. There was no documentation to explain that the patient refused the spiritual assessment and care. Clinical Record 12: The skilled nurse assessment was completed on 04/18/2024 and did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 04/23/2024 did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 13: The skilled nurse assessment completed on 06/15/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were blank. The Spiritual concerns section of the social worker assessment completed 06/18/20124 were left blank. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 14: The skilled nurse assessment completed on 06/18/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 06/18/2024 did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 15: The initial assessment completed on 02/28/2024 did not include a spiritual care assessment. The EMR had a spiritual assessment section in the RN assessment that was left blank. The social worker completed a social work assessment at the same time as the nurse on 02/28/2024 but did not address the spiritual assessment. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 16: The initial assessment completed on 03/21/2024 did not include a spiritual care component. The EMR had a spiritual assessment section in the RN assessment that was left blank. The social worker completed a social work assessment at the same time as the nurse on 03/21/2024 but did not address the spiritual assessment. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 17: The skilled nurse assessment completed on 04/27/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 05/06/2024 via phone did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. The clinical record contained no documentation to explain why the spiritual assessment was not completed or why the patient refused. Clinical Record 19: The skilled nurse assessment completed on 05/06/2024 did not include a spiritual assessment. The spiritual assessment questions in the EMR were left blank. The social work assessment completed on 05/07/2024 did not include a spiritual assessment and the spiritual assessment questions in the EMR were left blank. There was no documentation to explain why the spiritual assessment was not completed or why the patient refused. The director of nursing stated in an interview on 06/26/2024, “Oh, I didn’t know we had to do a spiritual assessment, we just ask them if they want it, and if they say they have their own priest or whatever we don’t do it.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed it was revealed that the agency did not ensure that the aide care plans were complete with all necessary information for the aide. Clinical Record 3: The comprehensive assessment completed on 06/21/2024 revealed that the patient had a blister on her right heel with an Allevyn dressing applied. The aide care plan dated 06/21/2024 to current did not provide the aide with direction related to the right heel and the dressing. There was no mention at all on the aide care plan related to who to notify of any issues related to the patient’s wound or dressing. Clinical Record 6: The initial assessment completed on 06/04/2024 revealed that the patient had a pressure ulcer on the right heel draining purulent drainage. The plan of care dated 06/04/2024 - 09/01/2024 revealed that the patient required daily dressing changes to the right heel per the facility staff. The aide care plan developed on 06/04/2024 did not provide any information or direction to the aide related to the right heel or who to notify related to issues with the dressing on the right heel. On 06/27/2024, after a clinical record review, the Director of nursing confirmed that the aide care plans did not include the required direction for the aide to notify the nurse of any issues related to the patient’s wound dressing.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed it was revealed that the agency did not ensure that the aide provided services at the frequency ordered on the plan of care. Clinical Record 4: The Plan of Care dated 5/20/2024- 8/17/2024 included an aide frequency of 1V x 1W, 2V x 12 W starting the week of 05/20/2024. The clinical record revealed there was no documentation that the aide visit was completed. There was no documentation in the clinical record to explain a missed visit or to indicate that the physician was notified of a missed visit. In interview on 06/27/2024, the Director of Nursing confirmed that there was no completed aide note for the ordered one-time aide visit for the week of 05/20/2024.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by interview and personnel record review. In 5 of 5 (100%) personnel records reviewed of staff hired after September 2021, it was revealed that the agency did not ensure that education related to the hospice philosophy was included in orientation. Personnel Record 1: The date of hire (DOH) for the registered nurse was 02/12/2024. The personnel file and education records contained no evidence of training and education related to the hospice philosophy. Personnel Record 5: The DOH for the Chaplain was 12/19/2022. The personnel file and education records contained no evidence of training and education related to the hospice philosophy. Personnel Record 6: The DOH for the Chaplain was 05/01/2023. The personnel file and education records contained no evidence of training and education related to the hospice philosophy. Personnel Record 7: The DOH for the social worker was 09/19/2022. The personnel file and education records contained no evidence of training and education related to the hospice philosophy. Personnel Record 9: The DOH for the Volunteer Coordinator was 03/18/2024. The personnel file and education records contained no evidence of training and education related to the hospice philosophy. In interview on 06/28/2024, Director of Nursing confirmed that education related to hospice philosophy was not included as a part of the orientation.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by document review and personnel record review. In 3 of 5 (60%) applicable personnel records reviewed it was revealed that the agency did not ensure that a skills check competency was completed on all individuals. Document 5: Agency policy no. 1-005.1 under section Personnel Administration, Categories/Qualifications of Personnel, revised April 2021 stated in part, “Competency 1. Professional Personnel: Individuals must demonstrate their competency, within their orientation or probationary period according to the orientation checklist developed for each category of organization personnel. Personnel Record 1: The registered nurse was hired 02/12/2024. The personnel record contained no evidence of a skills check to demonstrate competency. Personnel Record 6: The date of hire was 05/01/2023. The personnel record included a 4-page competency assessment tool that was completely blank. There was no evidence that a competency assessment or skills check was completed. Personnel Record 7: The date of hire was 09/19/2022. Personnel records contained no competency skills checklist. In interview on 06/28/2024, the Office Manager who was responsible for the employee records confirmed that the personnel records did not include competency assessments.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed it was revealed that the agency did not ensure that the plan of care included appropriate orders for all identified needs. Clinical Record 2: The plan of care for the episode 05/31/2023 - 07/29/2024 included the diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, other obstructive and reflux uropathy, encounter for fitting and adjustment of urinary device, and unspecific hydronephrosis. The comprehensive nursing assessment dated 04/01/2024 and the SN visit dated 05/30/2024 both indicated that the patient had a Foley catheter in place. The plan of care did not include any orders for a foley catheter or skilled nursing interventions for catheter care, monitoring, or maintenance. Clinical Record 3: The skilled nurse initial comprehensive assessment completed 06/21/2024 revealed that the patient had a blister on the right heel with an Allevyn dressing intact. The plan of care for the episode 6/21/2024 - 09/18/2024 did not include orders or interventions for the wound. The plan of care stated “May insert Foley catheter if needed”, but did not include the indications for warranting insertion, the size of the Foley catheter or balloon size to be used, or any orders for maintenance of the Foley catheter. Clinical Record 11: The plan of care dated 06/13/2024 - 09/10/2024 included an order that read, “May insert foley catheter if needed. The order did not include size of the Foley catheter, size of balloon, or indications for a foley catheter to meet this specific patient’s needs. Director of Nursing reviewed clinical records on 06/25/2024 and 06/27/2024 and confirmed that the orders and interventions were not included on the plans of care.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of live discharges it was revealed that the agency did not ensure that a discharge summary was completed and forwarded to the Medicare facility after the live discharge. Clinical Record 15: The patient revoked hospice care on 05/21/2024 after a fall resulting in left rib pain. The patient reported the desire to seek aggressive treatment. The discharge summary in the clinical record was blank and there was no evidence that the discharge summary was sent to the facility where the patient was seeking active treatment. In interview on 06/28/2024 after review of the clinical record, the Director of Nursing confirmed that the discharge summary was blank and there was no documented evidence that care was coordinated with the facility receiving the patient.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of discharged patients, it was revealed that the agency did not ensure that a discharge summary was sent to the patient’s attending physician after the patient’s revocation from hospice care. Clinical Record 16: The clinical record revealed that the patient revoked hospice services on 06/10/2024 stating that they want to have labs drawn and possibly reinstate dialysis. The discharge summary template in the clinical record was blank. There was no evidence in the clinical record that a discharge summary was completed and provided to the patient’s attending physician. In interview on 06/28/2024 after review of the clinical record, the Director of Nursing confirmed that the discharge summary was blank and there was no documented evidence that care was coordinated with the attending physician.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records of patients that were discharged, it was revealed that the agency did not ensure that a discharge summary was completed that contained all required elements. Clinical Record 15: The patient signed a revocation form on 05/21/2024 and was discharged. There was no evidence of a discharge summary. The discharge summary template in the medical record was blank. Clinical Record 16: The patient signed a revocation form on 06/10/2024 and was discharged. There was no evidence of a discharge summary. The discharge summary template in the medical record was blank. In interview on 06/28/2024 after review of the clinical records, the Director of Nursing confirmed that the discharge summaries were blank.”