Midwest Hospice Inc.

“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 FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice: Failed to ensure that the Interdisciplinary Group completed the patient’s initial comprehensive assessments within five calendar days after admission {HCPC.9. I/L523; and Failed to ensure an initial bereavement risk assessment, focusing on the social, spiritual, and cultural factors that could impact the family and other’s ability to cope with the patient’s death, was included in the comprehensive assessment and performed per agency policy. (HCPC.13. I/L531}. 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 FINDING 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 individualized written plan of care included the scope and frequency of services necessary to meet the specific needs of the patient and family{HCPC.21.I/L547} and Failed to ensure that the individualized written plan of care included drugs and treatment necessary to meet the patient’s specific needs {HCPC.21. I/L549}. 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 all hospice aide provides services ordered by the Interdisciplinary Group and Included in the plan of care. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that the Registered Nurse prepared specific written patient care instructions for the aide to follow{HCDT.15.I/L625}; and Failed to ensure the Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to supervise the quality of care and services provided by the hospice aide {HRSM. 25. I/L629. 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 418.76. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that a patient clinical record containing past and current findings 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 clinical record may be maintained electronically. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews with the which revealed the hospice: Failed to ensure that the clinical record included updated plans of care and updated comprehensive assessments {HSIM.3. I/L672}; and Failed to ensure the entries in the patient records were appropriately authenticated by the person performing the care or service {HSIM.4. I/ L679}. 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 418.104: 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 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, per 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 14 of 14 (100%) clinical records reviewed, it was revealed that the agency did not ensure the hospice Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment was completed on 09/19/2024 followed by the initial spiritual assessment on 09/24/2024. There was no evidence of a visit completed by the medical social worker. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial and emotional aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 2: The patient elected the hospice benefit on 08/06/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment was completed on 08/06/2024 followed by the initial spiritual assessment on 08/21/2024, 15 days after the patient elected the hospice benefit and 10 days outstanding. The medical social worker (MSW) visit dated 08/14/2024 included narrative documentation that the visit was performed to explain the role of the hospice MSW. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial, emotional, and spiritual aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 3: The patient elected the hospice benefit on 09/13/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment was completed on 09/13/2024. There was no evidence of visits completed by the medical social worker and chaplain. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial, emotional, and spiritual aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 4: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of malignant neoplasm of unspecified site of an unspecified female breast. The initial nursing assessment was completed on 09/19/2024 followed by the initial spiritual assessment on 09/24/2024. There was no evidence of a visit completed by the medical social worker. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial and emotional aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 5: The patient elected the hospice benefit on 10/30/2023 with a terminal diagnosis of moderate protein-calorie malnutrition. The initial nursing assessment was completed on 10/20/2023 followed by the initial spiritual assessment on 11/30/2023, 32 days after the patient elected the hospice benefit and 27 days outstanding. The first documented medical social worker visit was dated 07/22/2024. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial, emotional, and spiritual aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 6: The patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment was completed on 06/20/2024 followed by the initial spiritual assessment on 06/24/2024. The medical social worker (MSW) documented attempts to schedule a visit with the patient and family on 07/20/2024 and 07/29/2024. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial and emotional aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 7: The patient elected the hospice benefit on 10/03/2023 with a terminal diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. The initial nursing assessment was completed on 10/03/2023 followed by the initial spiritual assessment on 11/30/2023, 59 days after the patient elected the hospice benefit and 54 days outstanding. The first documented medical social worker visit was dated 07/23/2024. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial, emotional, and spiritual aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 8: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of acute respiratory failure with hypoxia. The initial nursing assessment was completed on 02/27/2024 followed by the initial spiritual assessment on 03/15/2024, 17 days after the patient elected the hospice benefit and 12 days outstanding. The was no evidence of a visit completed by the medical social worker. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial, emotional, and spiritual aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 9: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of severe hypoxic-ischemic encephalopathy. The initial nursing assessment was completed on 12/08/2023 followed by the initial spiritual assessment on 12/22/2023, 14 days after the patient elected the hospice benefit and nine (9) days outstanding. There was no evidence of a visit completed by the medical social worker. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial, emotional, and spiritual aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 10: The patient elected the hospice benefit on 07/09/2024 with a terminal diagnosis of unspecified malignant (primary) neoplasm. The initial nursing assessment was completed on 07/09/2024 followed by the initial spiritual assessment on 07/11/2024. The medical social worker visit dated 07/24/2024 included narrative documentation of self-introduction, the role of the hospice MSW, and the ability to provide resources if needed. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial and emotional aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 11: The patient elected the hospice benefit on 02/09/2024 with a terminal diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations. The patient was transferred to another hospice on 02/27/2024. The initial nursing assessment was completed on 02/09/2024 followed by the initial spiritual assessment on 02/15/2024. There was no evidence of a visit completed by the medical social worker. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial and emotional aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 12: The patient elected the hospice benefit on 02/06/2024 with a terminal diagnosis of Ischemic cardiomyopathy. The patient was transferred to another hospice on 02/28/2024. The initial nursing assessment was completed on 02/06/2024 followed by the initial spiritual assessment on 02/11/2024. The was no evidence of a visit completed by the medical social worker. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial and emotional aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 13: The patient elected the hospice benefit on 09/21/2023 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient died at the assisted living facility on 10/15/2023. The initial nursing assessment was completed on –09/21/2023. There was no evidence of visits completed by the medical social worker and the chaplain. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial, emotional, and spiritual aspects, was completed within five (5) calendar days of the patient electing hospice care. Clinical Record 14: The patient elected the hospice benefit on 04/01/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The patient died at the assisted living facility on 07/18/2024. The initial nursing assessment was completed on 04/01/2024 followed by the initial spiritual assessment on 04/16/2024, 15 days after the patient elected the hospice benefit and 10 days outstanding. There was no evidence of a visit completed by the medical social worker. The clinical record contained no evidence that the initial comprehensive assessment, including the psychosocial and emotional aspects, was completed within five (5) calendar days of the patient electing hospice care. During joint clinical record reviews and interviews on 10/03/2024, the Executive Director (ED), confirmed the clinical records identified contained no evidence that the initial comprehensive assessment, including psychosocial, emotional, and spiritual aspects, was completed by the Interdisciplinary Group (IDG) within five (5) calendar days of the patient electing hospice care. The ED stated that the medical social worker (MSW) was unable to enter or upload the psychosocial assessment but had reported the visits and assessment findings during bi-weekly IDG meetings and on work logs. The ED stated the chaplain provided discussions during bi-weekly Interdisciplinary Group meetings on the completed assessments and the inability to retrieve the information from the EMR. The ED confirmed there was no evidence of the visits or documented discussions completed by the MSW and/or chaplain in the clinical records identified.”

“It is required that the comprehensive assessment includes 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 14 of 14 (100%) clinical records reviewed, it was revealed that the agency did not ensure an initial bereavement risk assessment, focusing on the social, spiritual, and cultural factors that could impact the family and other’s ability to cope with the patient’s death, was included in the comprehensive assessment and performed per agency policy. Document 4: Agency policy #804 Bereavement Services, dated January 2024, stated in part, “The Hospice social worker and/or spiritual counselor will complete a comprehensive assessment of the primary caregiver for risk of poor coping, special needs or complicated bereavement after the patient’s death in addition to the patient’s coping ability and need for grief support. Ongoing assessments will be part of the ongoing comprehensive assessments. The bereavement assessment includes a) patient/family grief and/or loss issues, b) survivor needs, c) social, spiritual, cultural issues, d) services to be provided, e) referrals to be made, f) grief risk factors, and g) potential for pathological grief reactions.” Clinical Record 1: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The chaplain’s initial assessment was completed on 09/24/2024. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 08/06/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The chaplain’s initial assessment was completed on 08/21/2024, and the medical social worker (MSW) visit dated 08/14/2024 included narrative documentation regarding the hospice MSW role. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 09/13/2023 with a terminal diagnosis of Alzheimer’s disease with early onset. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 4: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of malignant neoplasm of unspecified site of an unspecified female breast. The chaplain’s initial assessment was completed on 09/24/2024. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 5: The patient elected the hospice benefit on 10/30/2023 with a terminal diagnosis of moderate protein-calorie malnutrition. The chaplain’s initial assessment was completed on 11/30/2023. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 6: The patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The chaplain’s initial assessment was completed on 06/24/2024, and the medical social worker (MSW) visit on 08/23/2024 included narrative documentation regarding the hospice MSW role. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 7: The patient elected the hospice benefit on 10/03/2023 with a terminal diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. The chaplain’s initial assessment was completed on 11/30/2023. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 8: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of Acute respiratory failure with hypoxia. The chaplain’s initial assessment was completed on 03/15/2024. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 9: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of Severe hypoxic-ischemic encephalopathy. The chaplain’s initial assessment was completed on 12/22/2023. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 07/09/2024 with a terminal diagnosis of unspecified malignant (primary) neoplasm. The chaplain’s initial assessment was completed on 07/11/2024, and the medical social worker (MSW) visit dated 07/24/2024 included narrative documentation of self-introduction, role, and ability to provide resources if needed. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 11: The patient elected the hospice benefit on 02/09/2024 with a terminal diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations. The patient was transferred to another hospice on 02/27/2024. The chaplain’s initial assessment was completed on 02/15/2024. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 12: The patient elected the hospice benefit on 02/06/2024 with a terminal diagnosis of Ischemic cardiomyopathy. The patient was transferred to another hospice on 02/28/2024. The chaplain’s initial assessment was completed on 02/11/2024. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 13: The patient elected the hospice benefit on 09/21/2023 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient died at the assisted living facility on 10/15/2023. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. Clinical Record 14: The patient elected the hospice benefit on 04/01/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The patient died at the assisted living facility on 07/18/2024The chaplain’s initial assessment was completed on 04/16/2024. The clinical record contained no evidence that the social worker or spiritual counselor performed an initial bereavement risk assessment, per agency policy, as part of the comprehensive assessment. During joint clinical record reviews and interviews on 10/03/2024, the Executive Director and Patient Care Administrator confirmed that the clinical records identified contained no evidence of an initial bereavement risk assessment. The ED stated that the Chaplain provided discussions during bi-weekly Interdisciplinary Group meetings on the completed assessments and the inability to retrieve the information from the EMR.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: 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 14 of 14 (100%) clinical records reviewed, it was revealed that the agency did not ensure the individualized written plan of care included the scope and frequency of services necessary to meet the specific needs of the patient and family. Clinical Record 1: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient received documented care and services from skilled nursing and chaplain, from 09/19/2024 through the current date. The plan of care, electronically signed and dated 09/19/2024, did not include a visit frequency for skilled nursing and the chaplain. Clinical Record 2: The patient elected the hospice benefit on 08/06/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient received documented care and services from skilled nursing, hospice aide, medical social worker (MSW), and chaplain, from 08/06/2024 through the current date. The plan of care, electronically signed and dated 08/06/2024, did not include a visit frequency for skilled nursing, the hospice aide, the MSW, and the chaplain. Clinical Record 3: The patient elected the hospice benefit on 09/13/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient received documented care and services from skilled nursing and hospice aide, from 09/13/2024 through the current date. The plan of care, electronically signed and dated 09/13/2024, did not include a visit frequency for skilled nursing and the hospice aide. Clinical Record 4: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of malignant neoplasm of unspecified site of unspecified female breast. The patient received care and services from skilled nursing, from 09/19/2024 through the current date. The plan of care, electronically signed and dated 09/19/2024, did not include a visit frequency for skilled nursing. Clinical Record 5: The patient elected the hospice benefit on 10/30/2023 with a terminal diagnosis of moderate protein-calorie malnutrition. The patient received care and services from skilled nursing, hospice aide, medical social worker (MSW), and chaplain, from 10/20/2023 through the current date. The plan of care, electronically signed and dated 10/30/2023, did not include a visit frequency for skilled nursing, the hospice aide, the MSW, and the chaplain. Clinical Record 6: The patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient received care and services from skilled nursing, hospice aide, medical social worker (MSW), and chaplain, from 06/20/2024 through the current date. The plan of care, electronically signed and dated 06/20/2024, did not include a visit frequency for skilled nursing, the hospice aide, the MSW, and the chaplain. Clinical Record 7: The patient elected the hospice benefit on 10/03/2023 with a terminal diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. The patient received care and services from skilled nursing, hospice aide, medical social worker (MSW), and chaplain, from 10/03/2023 through the current date. The plan of care, electronically signed and dated 10/03/2023, did not include a visit frequency for skilled nursing, the hospice aide, the MSW, and the chaplain. Clinical Record 8: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of Acute respiratory failure with hypoxia. The patient received care and services from skilled nursing and chaplain, from 02/27/2024 through the current date. The plan of care, electronically signed and dated 02/27/2024, did not include a visit frequency for skilled nursing and the chaplain. Clinical Record 9: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of severe hypoxic-ischemic encephalopathy. The patient received care and services from skilled nursing, hospice aide, and chaplain, from 12/08/2023 through the current date. The plan of care, electronically signed and dated 12/08/2023, did not include a visit frequency for skilled nursing, the hospice aide, and the chaplain. Clinical Record 10: The patient elected the hospice benefit on 07/09/2024 with a terminal diagnosis of unspecified malignant (primary) neoplasm. The patient received care and services from skilled nursing, hospice aide, medical social worker (MSW), and chaplain, from 07/09/2024 through the current date. The plan of care, electronically signed and dated 07/09/2024, did not include a visit frequency for skilled nursing, the hospice aide, the MSW, and the chaplain. Clinical Record 11: The patient elected the hospice benefit on 02/09/2024 with a terminal diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations. The patient was transferred to another hospice on 02/27/2024. The patient received care and services from skilled nursing and chaplain, from 02/09/24 through the date of discharge/transfer. The plan of care, electronically signed and dated 02/09/2024, did not include a visit frequency for skilled nursing and the chaplain. Clinical Record 12: The patient elected the hospice benefit on 02/06/2024 with a terminal diagnosis of Ischemic cardiomyopathy. The patient was transferred to another hospice on 02/28/2024. The patient received care and services from skilled nursing and chaplain, from 02/06/2024 through the date of discharge/transfer. The plan of care, electronically signed and dated 02/06/2024, did not include a visit frequency for skilled nursing and the chaplain. Clinical Record 13: The patient elected the hospice benefit on 09/21/2023 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient died at the assisted living facility on 10/15/2023. The patient received care and services from skilled nursing, from 09/21/2023 through the date of death. The plan of care, electronically signed and dated 09/21/2023, did not include a visit frequency for skilled nursing. Clinical Record 14: The patient elected the hospice benefit on 04/01/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The patient died at the assisted living facility on 07/18/2024. The patient received care and services from skilled nursing, hospice aide, and chaplain, from 04/01/2024 through the date of death. The plan of care, electronically signed and dated 04/01/2024, did not include a visit frequency for skilled nursing, the hospice aide, and the chaplain. During joint clinical record reviews and interviews on 10/03/2024, the Executive Director (ED) confirmed the individualized written plan of care did not include the scope and frequency of services to be provided. The ED stated that the Patient Care Administrator provides a weekly schedule for each discipline involved that includes when and how often the patient is to be seen. The ED confirmed that there was no physician order within the EMR or on paper that included a detailed statement of the scope and frequency of services to be provided.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed, it was revealed that the agency did not ensure the individualized written plan of care included drugs and treatment necessary to meet the patient’s specific needs. Clinical Record 1: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment on 09/19/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 09/19/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 2: The patient elected the hospice benefit on 08/06/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment on 08/06/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 08/06/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 3: The patient elected the hospice benefit on 09/13/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment on 09/13/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 09/13/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 4: The patient elected the hospice benefit on 09/19/2024 with a terminal diagnosis of malignant neoplasm of unspecified site of an unspecified female breast. The initial nursing assessment on 09/19/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 09/19/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 5: The patient elected the hospice benefit on 10/30/2023 with a terminal diagnosis of moderate protein-calorie malnutrition. The initial nursing assessment on 10/30/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 10/30/2023 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 6: The patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment on 06/20/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 06/20/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 7: The patient elected the hospice benefit on 10/03/2023 with a terminal diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. The initial nursing assessment on 10/03/2023 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 10/03/2023 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 8: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of acute respiratory failure with hypoxia. The initial nursing assessment on 02/27/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 02/27/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 9: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of severe hypoxic-ischemic encephalopathy. The initial nursing assessment on 12/08/2023 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 12/08/2023 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 10: The patient elected the hospice benefit on 07/09/2024 with a terminal diagnosis of unspecified malignant (primary) neoplasm. The initial nursing assessment on 07/09/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 07/09/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 11: The patient elected the hospice benefit on 02/09/2024 with a terminal diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations. The initial nursing assessment on 02/09/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 02/09/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 12: The patient elected the hospice benefit on 02/06/2024 with a terminal diagnosis of Ischemic cardiomyopathy. The initial nursing assessment on 02/06/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order dated 02/06/2024 did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 13: The patient elected the hospice benefit on 09/21/2023 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment on 09/21/2023 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order, electronically signed and dated 09/21/2023, did not include the drugs and treatments that were documented on the medication profile form. Clinical Record 14: The patient elected the hospice benefit on 04/01/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The initial nursing assessment on 04/01/2024 included a drug profile that was documented outside the electronic medical record on a medication profile form. The “Care Plan” order, electronically signed and dated 04/01/2024, did not include the drugs and treatments that were documented on the medication profile form. During joint clinical record reviews and interviews on 10/02/2024, the Executive Director (ED) and Patient Care Administrator (PCA) confirmed a drug profile was documented outside the medical record on a medication profile form and the plan of care (Care Plan order) did not include the drugs and treatments that were documented on the medication profile form. The ED and PCA stated that the Medical Director reviewed the medication profile form during bi-weekly Interdisciplinary Group meetings, and new medication and treatment orders were written on physician order forms due to the inability to input and retrieve the information from the EMR.”

“It is required hospice aides be assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group (IDG). Written patient care instructions for a hospice aide are prepared by the RN responsible for supervising the hospice aide. This standard was not met as evidenced by clinical record review, interview and observation. In 8 of 8 (100%) clinical records reviewed with hospice aide services provided, it was revealed that the agency did not ensure the Registered Nurse prepared specific written patient care instructions for the aide to follow. Clinical Record 2: The patient elected the hospice benefit on 08/06/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The hospice aide documented eight visits from 08/09/2024 to 09/09/2024 outside the electronic medical record (EMR) on a form titled, “Hospice Aide Visit Note.” It included documentation that the aide performed the following tasks: shower, clean nails, brush/comb hair, meal prep, and assist with dressing, standing, and ambulation. The identified form contained no evidence that the Registered Nurse had written specific patient care instructions for the aide to follow. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 09/13/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. During the home visit with the Hospice Aide (Personnel Record 2), the aide reported that she documented all visits performed on a paper form titled, “Hospice Aide Visit Note.” When asked how the aide received instructions on the care to be provided, the aide stated that a visit with the nurse before the aide’s first visit was completed for an introduction and to determine what care the patient and family wanted. The aide reported that the following tasks are provided two days a week: bed bath, shampoo, linen change, mouth care, clean nails, dress, and skin care. The identified form contained no evidence that the Registered Nurse had written specific patient care instructions for the aide to follow. Clinical Record 5: The patient elected the hospice benefit on 10/30/2023 with a terminal diagnosis of moderate protein-calorie malnutrition. The hospice aide documented six visits from 08/01/2024 to 08/22/2024 on a paper form titled, “Hospice Aide Visit Note.” It included documentation that the aide performed the following tasks: shower, clean nails, skin care with lotion, brush/comb/style hair, dress, meal prep, and assist with standing and ambulation. The identified form contained no evidence that the Registered Nurse had written specific patient care instructions for the aide to follow. Clinical Record 6: The patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The hospice aide documented six visits from 08/02/2024 to 08/28/2024 outside the electronic medical record (EMR) on a paper form titled, “Hospice Aide Visit Note.” It included documentation that the aide performed the following tasks: shower, shower bench/chair, brush/comb/style hair, assist with dressing, meal prep, and assistance with standing and ambulation. The identified form contained no evidence that the Registered Nurse had written specific patient care instructions for the aide to follow. Clinical Record 7: The patient elected the hospice benefit on 10/03/2023 with a terminal diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. The hospice aide documented ten visits from 07/29/2024 to 09/23/2024 outside the electronic medical record (EMR) on a paper form titled, “Hospice Aide Visit Note.” It included documentation that the aide performed the following tasks: bed bath, clean nails, brush/comb hair, assist with dressing and meal prep. The identified form contained no evidence that the Registered Nurse had written specific patient care instructions for the aide to follow. Clinical Record 9: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of severe hypoxic-ischemic encephalopathy. The hospice aide documented three visits from 08/06/2024 to 08/22/2024 outside the electronic medical record (EMR) on a paper form titled, “Hospice Aide Visit Note.” It included documentation that the aide performed the following tasks: shower, clean nails, brush/comb hair, meal prep, and assist with dressing, standing, and ambulation. The identified form contained no evidence that the Registered Nurse had written specific patient care instructions for the aide to follow. Clinical Record 10: The patient elected the hospice benefit on 07/09/2024 with a terminal diagnosis of unspecified severe hypoxic-ischemic encephalopathy. The hospice aide documented eight visits from 07/16/2024 to 09/08/2024 on a paper form titled, “Hospice Aide Visit Note.” It included documentation that the aide performed the following tasks: shower, shampoo, brush, comb hair, meal prep, and assist with dressing and ambulation. The identified form contained no evidence that the Registered Nurse had written specific patient care instructions for the aide to follow. Clinical Record 14: The patient elected the hospice benefit on 04/01/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The hospice aide documented four visits from 06/17/2024 to 06/26/2024 outside the electronic medical record (EMR) on a paper form titled, “Hospice Aide Visit Note.” It included documentation that the aide performed the following tasks: shower, clean nails, brush/comb hair, meal prep, assist with dressing, standing, and ambulation, and light housekeeping. The identified form contained no evidence that the Registered Nurse had written specific patient care instructions for the aide to follow. During joint clinical record reviews and interviews on 10/03/2024, the Executive Director (E D) confirmed that the form, “Hospice Aide Visit Note,” did not provide the hospice aide with patient care instructions prepared by the Registered Nurse (RN). The ED reported the agency had significant issues with the current electronic medical record (EMR) that resulted in lost data or the inability to enter data including patient care instructions for the hospice aide. The ED stated that the RN gave the aide verbal instructions during bi-weekly Interdisciplinary Group meetings.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 7 of 8 (88%) clinical records reviewed of patients that received hospice aide services it was revealed that the agency did not ensure the Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to supervise the quality of care and services provided by the hospice aide. Clinical Record 2: The patient elected the hospice benefit on 08/06/2024. The hospice aide documented that visits were performed from 08/09/2024 through 09/09/2024. The clinical record contained no evidence of a documented supervisory visit on-site by the Registered Nurse from 08/09/2024 through 09/09/2024, 31 days of hospice aide services provided. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 09/13/2024. During the home visit the hospice aide reported visits were completed by the aide to provide personal care twice a week since the week of 09/15/2024. The clinical record contained no evidence of a documented supervisory visit on-site by the Registered Nurse from 09/15/2024 through the date of the home visit (10/02/2024), 16 days of hospice aide services provided. Clinical Record 5: The patient elected the hospice benefit on 10/30/2023. The hospice aide documented that visits were performed from 08/01/2024 through 08/22/2024. The clinical record contained no evidence of a documented supervisory visit on-site by the Registered Nurse from 08/01/2024 through 08/22/2024, 21 days of hospice aide services provided. Clinical Record 6: The patient elected the hospice benefit on 06/20/2024. The hospice aide documented that visits were performed from 08/02/2024 through 08/28/2024. The clinical record contained no evidence of a documented supervisory visit on-site by the Registered Nurse from 08/02/2024 through 08/28/2024, 26 days of hospice aide services provided. Clinical Record 7: The patient elected the hospice benefit on 10/03/2023. The hospice aide documented that visits were performed from 07/29/2024 through 09/23/2024. The Registered Nurse (RN) documented an aide supervisory visit outside the electronic medical record on a hospice aide supervisory visit form on 05/22/2024 and 07/18/2024. The clinical record contained no evidence that the RN performed supervisory visits from 07/29/2024 through 09/23/2024, 56 days of hospice aide services. Clinical Record 9: The patient elected the hospice benefit on 12/08/2023. The hospice aide documented that visits were performed from 08/06/2024 through 08/22/2024. The Registered Nurse (RN) documented an aide supervisory visit outside the electronic medical record on a hospice aide supervisory visit form on 08/29/2024, 23 days from the first aide visit documented for the benefit period starting 08/04/2024, and nine (9) days outstanding. Clinical Record 10: The patient elected the hospice benefit on 07/09/2024. The hospice aide documented that visits were performed from 07/16/2024 through 09/08/2024. The clinical record contained no evidence of a documented supervisory visit on-site by the Registered Nurse from 07/16/2024 through 09/08/2024, 54 days of hospice aide services provided. During joint clinical record reviews and interviews on 10/02/2023, the Executive Director (ED) and Patient Care Administrator (PCA) confirmed the clinical records identified contained no evidence of hospice aide supervisory visits completed no less frequently than every 14 days. The ED and PCA reported the agency had significant issues with the current electronic medical record (EMR) that resulted in lost data or the inability to enter data including supervisory visits. The ED and PCA confirmed that a supervisory visit form outside the EMR was used to document the supervision of the hospice aide and then uploaded into the EMR; however, retrieving the data once uploaded was a current issue with the EMR.”

“It is required that a patient clinical record containing past and current findings 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. Each patient’s record includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, it was revealed that the agency did not ensure that the patient’s clinical record included updated plans of care. Clinical Record 5: The patient elected the hospice benefit on 10/30/2023 with a terminal diagnosis of moderate protein-calorie malnutrition. The patient entered the fifth hospice benefit period on 08/25/2024. The clinical record contained no evidence of an updated plan of care for the benefit periods starting 01/27/2024, 04/27/2024, 06/26/2024, and 08/25/2024. Clinical Record 6: The patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient entered the second hospice benefit period on 09/18/2024. The clinical record contained no evidence of an updated plan of care for the benefit period starting 09/18/2024. Clinical Record 7: The patient elected the hospice benefit on 10/03/2023 with a terminal diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. The patient entered the sixth hospice benefit period on 09/27/2024. The clinical record contained no evidence of an updated plan of care for the benefit periods starting 12/31/2023, 03/31/2024, 05/30/2024, 07/29/2024, and 09/27/2024. Clinical Record 8: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of acute respiratory failure with hypoxia. The patient entered the third hospice benefit period on 08/25/2024. The clinical record contained no evidence of an updated plan of care for the benefit periods starting 05/27/2024 and 08/25/2024. Clinical Record 9: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of severe hypoxic-ischemic encephalopathy. The patient entered the fourth hospice benefit period on 08/04/2024. The clinical record contained no evidence of an updated plan of care for the benefit periods starting 03/07/2024, 06/05/2024, and 08/04/2024. Clinical Record 14: The patient elected the hospice benefit on 04/01/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The patient died at the assisted living facility on 07/18/2024. The patient entered the second hospice benefit period on 06/30/2024. The clinical record contained no evidence of an updated plan of care for the benefit period starting 06/30/2024. During joint clinical record reviews and interviews on 10/03/2024, the Executive Director and Patient Care Administrator confirmed the clinical records identified contained no evidence that plans of care had been updated for each new benefit period. The ED reported the agency had significant issues with the current electronic medical record (EMR) that resulted in lost data or the inability to enter data including updates to the plan of care. The ED reported that the plan of care is reviewed, revised, and updated during bi-weekly Interdisciplinary Group meetings, and written physician orders are obtained and documented outside of the EMR. The ED confirmed written updated plan of care was not evident in the clinical records identified.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 6 of 6 (100%) clinical records reviewed with the patient recertified for another hospice benefit period, it was revealed that the agency did not ensure the clinical record included documentation of a written and signed recertification of the terminal illness completed by the medical director no later than two (2) calendar days after the first day of each benefit period and no more than 15 days before the next benefit period began. Clinical Record 5: The patient elected the hospice benefit on 10/30/2023 with a terminal diagnosis of moderate protein-calorie malnutrition. The patient entered the fifth hospice benefit period on 08/25/2024. The clinical record contained no evidence of a written and signed recertification of the terminal illness by the hospice medical director for the benefit periods starting 01/27/2024, 04/27/2024, 06/26/2024, and 08/25/2024. Clinical Record 6: The patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The patient entered the second hospice benefit period on 09/18/2024. The clinical record contained no evidence of a written and signed recertification of the terminal illness by the hospice medical director for the benefit period starting 09/18/2024. Clinical Record 7: The patient elected the hospice benefit on 10/03/2023 with a terminal diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. The patient entered the sixth hospice benefit period on 09/27/2024. The clinical record contained no evidence of a written and signed recertification of the terminal illness by the hospice medical director for the benefit periods starting 12/31/2023, 03/31/2024, 05/30/2024, 07/29/2024, and 09/27/2024. Clinical Record 8: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of acute respiratory failure with hypoxia. The patient entered the third hospice benefit period on 08/25/2024. The clinical record contained no evidence of a written and signed recertification of the terminal illness by the hospice medical director for the benefit periods starting 05/27/2024 and 08/25/2024. Clinical Record 9: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of severe hypoxic-ischemic encephalopathy. The patient entered the fourth hospice benefit period on 08/04/2024. The clinical record contained no evidence of a written and signed recertification of the terminal illness by the hospice medical director for the benefit periods starting 03/07/2024, 06/05/2024, and 08/04/2024. Clinical Record 14: The patient elected the hospice benefit on 04/01/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The patient died at the assisted living facility on 07/18/2024. The patient entered the second hospice benefit period on 06/30/2024. The clinical record contained no evidence of a written and signed recertification of the terminal illness by the hospice medical director for the benefit period starting 06/30/2024. During joint clinical record reviews and interviews on 10/03/2024, the Executive Director (ED), confirmed the clinical records identified contained no evidence of the written and signed recertification of the terminal illness by the hospice medical director. The ED reported the agency had significant issues with the current electronic medical record (EMR) that resulted in lost data or the inability to enter data including the written recertification of the terminal illness. The ED stated that the Medical Director attended the Interdisciplinary Group meetings every two weeks, obtained medical data relevant to the patient’s comfort, care, and eligibility, and used the collected data to write the recertifications of terminal illness. Contract 5: During an interview on 10/02/2024 with the hospice Medical Director, the Medical Director confirmed the difficulties with entering data and signing orders within the EMR. The Medical Director stated that because of the reported EMR issues the medical director visits the office approximately three times a week to sign physician orders and hand-write recertifications of terminal illness.”