Buckeye Hospice Care LLC

“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 3 of 9 (33%) clinical records reviewed of patients with aide services, it was revealed that the agency did not ensure that the home health aide care plan provided specific direction for the aide. Clinical Record 2: The nursing assessment dated 01/01/2024 described a wound on the right foot. Physician orders dated 01/01/2024 prescribed wound care and dressings. The aide care plan dated 01/03/2024 did not mention wounds or provide any direction to the aide related to care of the wound areas when providing personal care. Clinical Record 5: The nursing assessment dated 01/24/2024 described a wound to the right heel. Physician orders dated 01/24/2024 prescribed wound care and dressings. The aide care plan dated 01/25/2024 did not mention wounds or provide any direction to the aide related to care of the wound areas when providing personal care. Clinical Record 8: The nursing assessment dated 01/12/2024 described bilateral heel wounds and a pressure ulcer to the coccyx. Physician orders dated 01/12/2024 prescribed wound care and dressings. The aide care plan dated 01/12/2024 did not mention wounds or provide any direction to the aide related to care of the wound areas when providing personal care. In an interview on 02/06/2024, the Clinical Director confirmed that care plans did not address patient-specific needs and stated she would update all aide care plans.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed for patients receiving aide services it was revealed that the agency did not ensure that the aide followed the plan of care. Clinical Record 8: The aide care plan dated 01/04/2024 read in part, “Shower with shower chair weekly first visit of the week, and independent with feeding”. The aide visit note dated 01/12/2024 revealed that the aide documented giving the patient a bed bath. The aide also documented that the patient was a dependent feed and did not complete the task of independent feeding. There is no documentation of notification to the RN. In an interview on 02/06/2024, the Clinical Director confirmed the findings after reviewing the record.”

“It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or the patient’s legal representatives. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 4 (50%) clinical records reviewed of discharged patients revealed the agency did not ensure that the disposal of controlled medications was documented. Document 1: Agency Policy PC.M60 dated 1/3/2023, titled Medication Use and Disposal of Controlled Substances, read in part, “Controlled drugs containing opioids no longer needed by the patient are disposed of in compliance with State and Federal regulations and disposal instructions and activities are documented”. Clinical Record 7: The nursing death visit was completed on 01/07/2024. The patient was residing at an assisted living facility. The medication record documented that the patient had an order for “Morphine 20mg/ml, give 10mg every 2 hours as needed for pain or air hunger”. There is no evidence in the clinical record that medication disposal was completed. Clinical Record 8: The nursing death visit was completed on 01/13/2024. The patient was residing at an assisted living facility. The medication record documented the patient had an order for Morphine 20mg/ml, give 10mg every 2 hours as needed for pain or air hunger”. There is no evidence in the clinical record that medication disposal was completed. In an interview on 02/08/2024, the Administrator stated, “The assisted living facility destroys the medications”, and verbalized the understanding for the need to document medication disposal.”

“It is required that the hospice conducts 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 clinical record review, document review, interview and observation which revealed that the agency failed to ensure update of the comprehensive assessment was completed as frequently as the condition of the patient required, but no less frequently than every 15 days [HCPC.17.I/L533]; failed to ensure that an initial bereavement risk assessment of the needs of the patient’s family was completed [HCPC.13.I/L531]; failed to ensure a comprehensive medication reconciliation was accurately completed [HCPC.15.I/L530]; failed to ensure the comprehensive assessment included all required elements [HCPC.11.I/L529]; and failed to ensure a complete initial comprehensive assessment was completed within five (5) days of the election of hospice care [HCPC.9.I/L523]. This collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care services from the agency.”

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepares 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 clinical record review, document review and interview which revealed the agency failed to ensure a written plan of care was initiated and reviewed no less frequently than every 15 days [HCPC.21.I/L552]; failed to ensure plans of care included a detailed statement of the scope and frequency of services to be provided [HCPC.21.I/L547]; failed to ensure that services were provided as ordered on the plan of care [HCPC.19.I/L543]; and failed to ensure that services were coordinated with other health care providers [HCPC.19.I/L540]. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care services from 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, 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 4 of 14 (29%) records reviewed it was revealed that the hospice agency did not ensure a complete initial comprehensive assessment was completed within five (5) days of the election of hospice care. Clinical Record 1: The hospice benefit election date was 11/6/2023. The initial RN assessment completed on 11/6/2023, did not include completion of the psychosocial assessment, which was blank, and the spiritual assessment was documented as “not completed”. The record contained a Social Worker note on 11/7/2023 that stated in part, “MSW attempted to contact patient/family to schedule an initial visit. MSW reviewed, but there was no answer. MSW will contact the family at a later date.” There was no additional documentation of a second attempt to meet with the patient and family by the Social Worker. The first Chaplain note was dated 12/1/2023 and stated in part, “Patient was stated to be doing well at this time, and Chaplain provided active listening. No Spiritual assessment was completed. Clinical Record 2: The hospice benefit election date was 12/16/2023. The initial assessment completed by the RN did not include a completed Spiritual assessment. The Chaplain visit dated 12/21/2023 did not contain an initial bereavement risk assessment or spiritual assessment. The visit notes sub-section titled Spiritual/General Spiritual Assessment Details comment stated in part, “Patient would like spiritual support and companionship.” Clinical Record 3: The hospice benefit election date was 12/21/2023. The Chaplain visit dated 12/22/2023 included a sub-section titled Spiritual/General Spiritual Assessment Details comment that stated in part, “Patient would like spiritual support and companionship.” The initial RN assessment on 12/21/2023 sub-section spiritual stated in part, “ “Was patient/caregiver asked about Spiritual/Existential concerns? No.” Clinical Record 12: The hospice benefit election date was 9/8/2023. The Initial RN assessment dated 9/8/2023 did not contain documentation of a psychosocial assessment. The Social Worker contacted the caregiver via phone on 9/15/2023 seven (7) days after admission via phone to schedule a one-on-one visit. There was a phone call dated 9/16/2023 that stated in part, “Family cancelled Social Worker visit on this day. Communicated cancelled visit with the nurse.” A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the hospice did not ensure the Interdisciplinary Group (IDG) completed a comprehensive assessment to include psychosocial and spiritual needs within five (5) days of admission.”

“It is required that the comprehensive assessment includes consideration of the following factors: Symptoms and symptom severity, including skin integrity. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) records reviewed it was revealed that the hospice agency did not ensure the comprehensive assessment included all elements. Document 2: Policy #PC.A25 (no revision date) titled Admission to Hospice Care and Initial Assessment, sub-section four (4) stated in part, “The purpose of the initial visit will be to: (g) assess and document a description of the patient’s symptoms.” Clinical Record 3: The hospice benefit election date was12/21/2023. The initial RN assessment dated 12/21/2023 included a sub-section titled skin which stated “pale.” The narrative sub-section stated, “Patient recently had fallen and has skin tears to his LFA (left forearm), R (right) hand, and R (right) knee. He also has DTI (deep tissue injury) to his R (right heels). These will be changed three (3) times weekly/as needed (PRN).” The initial comprehensive assessment did not contain any skin/wound assessments with measurements of length, width, descriptions, stage, or condition of surrounding skin. The wound assessment form in the record was blank. Clinical Record 7: The hospice benefit election date was 12/5/2023. The initial RN assessment included a narrative sub-section that stated in part, “He has wounds to his L knee, L Achilles, and L lateral leg that will be changed three (3) times weekly. The sub-section titled Skin stated in part, “Pressure Ulcer/Surgical.” The Initial comprehensive assessment did not contain any skin/wound assessment documentation of measurements of length, width, descriptions, stage, or condition of surrounding skin. The wound assessment form in the record was blank. A joint record review and interview with the Clinical Director (staff 1) on 12/27/2023 confirmed there was no documentation of a comprehensive assessment of the patients’ identified wounds. They stated, “The wound assessment form should have been completed.””

“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, interview and observation. In 3 of 3 (100%) home visit observations where medication reconciliation was completed comparing the hospice agency medication profile to the patient’s current regimen, it was revealed that the hospice agency medication profile was not updated to include the patient’s current medication regimen. Home Visit 1: The visit was conducted on 12/28/2023 at an Assisted Living Facility (ALF) in the presence of the RN (staff 3). The hospice benefit election date was 12/21/2023 (record 3). The medication reconciliation was performed by comparing the hospice agency medication profile dated 12/28/2023 to the patient’s medication administration record provided by the ALF dated 12/28/2023. The hospice agency medication profile listed, “Diclofenac Sodium one (1) percent (%). Apply two (2) grams (GM) topical two (2) times a day. Diclofenac was ordered on admission to hospice and was not on the Assisted Living Facility medication list. The ALF medication record listed “Cephalexin five hundred (500) milligrams (mg) take one (1) capsule by mouth four (4) times a day for seven (7) days.” The medication Cephalexin was ordered 12/22/2023 and was not on the hospice agency medication list dated 12/28/2023. Home Visit 2: The visit was conducted on 12/28/2023 at an Assisted Living Facility (ALF). The hospice benefit election date was 12/16/2023 (record 2). The medication reconciliation was performed by comparing the hospice agency medication profile dated 12/28/2023 to the patient’s medication regimen/ medication administration record provided by the ALF dated 12/28/2023. The ALF medication list dated 12/28/2023 included Meloxicam fifteen (15) milligrams, one (1) tablet daily. The medication Meloxicam was not on the hospice agency medication profile dated 12/28/2023. The ALF medication list included Divalproex Sodium one hundred-twenty-five (125) milligrams, three (3) tabs orally two (2) times a day. The hospice agency medication list dated 12/28/2023 documented Divalproex Sodium one hundred-twenty-five (125) milligrams, one (1) tablet orally two (2) times a day. Home Visit 3: The visit was conducted on 12/28/2023 in the presence of the RN (staff 3). The hospice benefit election date was 11/6/2023 (record 1), and the patient was actively dying. The medication reconciliation was performed by comparing the hospice agency medication list dated 12/28/2023 to the patient’s current medication regimen. The hospice agency medication list included Aspirin eight-one (81) milligrams (mg), one (1) tablet daily, Carbidopa-Levodopa twenty-five (25)- one hundred (100) (25-100) two (2) tablets orally three (3) times daily, Lisinopril twenty (20) milligrams (mg), one tablet orally two (2) times a day, Metoprolol tartrate one hundred (100) milligrams (mg), one (1) tablet orally two (2) times a day. The caregiver (wife) reported the medications were stopped a week ago because the patient fell asleep and wouldn’t wake up. Per the wife, the patient was currently only taking two medications: Klonopin one (1) milligram one-half (0.5) tablets one (1) time a day, and Oxycodone five (5) milligrams (mg) one (1) tablet every four (4) hours as needed (PRN) for pain. A joint record review, interview, and observation with the RN (staff 3) confirmed the hospice agency medication profiles did not match the patient’s current regimen.”

“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. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 2 of 14 (14%) records reviewed it was revealed that the hospice agency did not ensure that an initial bereavement risk assessment of the needs of the patient’s family was completed. Document 6: Policy #PC.B25 (no revision date) titled Bereavement Risk Assessment stated in part, “Hospice patients and family members are assessed for grief and bereavement needs before and after the patient’s death. One (1) During the comprehensive assessment, an initial bereavement risk assessment is conducted to determine the factors that may impact the ability of family members and other involved individuals to cope with the patient’s death.” Clinical Record 2: The hospice benefit election date was 12/16/2023. There was no documentation of an initial bereavement risk assessment. The Chaplain visit on 12/21/2023 did not contain an initial bereavement risk assessment. The Chaplain’s visit on 12/16/2023 narrative sub-section stated in part, “Patient would like spiritual support and companionship.” The initial RN assessment on 12/16/2023 sub-section spiritual stated in part, “Was patient/caregiver asked about Spiritual/Existential concerns? No.” Clinical Record 3: The hospice benefit election date was 12/21/2023. did not have a completed bereavement risk assessment. The Initial RN The initial RN assessment on 12/21/2023 sub-section spiritual stated in part, “Was patient/caregiver asked about Spiritual/Existential concerns? No.” As of 12/29/2023, the record did not contain evidence that the Chaplain had attempted to contact the family/caregiver to complete a bereavement risk assessment. An interview was conducted with the Bereavement coordinator (staff 4) on 12/28/2023 in the presence of the RN (staff 3). The Bereavement Coordinator confirmed they did not complete the initial bereavement risk assessment. The Bereavement Coordinator reported they were not aware the agency was required to complete an initial bereavement risk assessment before death. A joint record review and interview with the Clinical Director (staff 1) on 12/27/2023 confirmed the hospice agency did not ensure a bereavement risk assessment was completed.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group. The update of the comprehensive assessment is completed as frequently as the condition of the patient requires, but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) records reviewed it was revealed that the hospice agency did not ensure that updates to the comprehensive assessment were completed by the hospice Interdisciplinary Group every fifteen (15) days. Document 3: Policy #PC.70 (no revision date) titled Comprehensive Assessment-Updated sub-section one (1) stated in part, “An update of the comprehensive assessment is conducted by the hospice interdisciplinary team as frequently as the patient’s condition warrants, but no less frequently than every fifteen (15 days). Clinical Record 5: The hospice benefit election date was 8/17/2023. The initial plan of care was dated 8/17/2023. During the second benefit period, the time frame from 11/9/2023 to 12/4/2023, there was no documentation that the patient received any skilled nurse visits and there were no documented updates to the comprehensive assessment. The patient received RN visits on 11/9/2023, 12/4/2023, and 12/18/2023. The last documented IDG notes were dated 10/17/2023. There was no patient specific IDG updates from 10/31/2023 to 11/28/2023 documented in any IDG meeting minutes. The patient did not receive an RN visit for twenty-four (24) days. Therefore, the comprehensive assessment was not updated. Clinical Record 6: The hospice benefit election date was 11/17/2023. No updates to the comprehensive assessment by the RN were documented for sixteen (16) days from 11/17/2023-12/4/2023. The patient received SN visits by the LPN dated 11/24/2023, 11/27/2023, and 12/1/2023. There were no IDG meeting notes or care plan updates documented in the record. The IDG meeting dates provided by the Executive Director were 11/28/2023, 12/12/2023, 12/21/2023, and 12/26/2023. A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the patient did not receive an RN visit for sixteen (16) days and the care plan was not updated because the patient was not assessed or discussed at the IDG meetings. A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the hospice agency did not ensure the comprehensive assessments were updated every fifteen (15) days. They stated, “We realized if the patient didn’t have any changes, we were not discussing the patient at the IDG meeting or updating the plan of care.” The agency had initiated a performance improvement project dated 12/24/2023.”

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) records reviewed it was revealed that the hospice agency did not ensure the coordination of care with non-hospice healthcare providers by the registered nurse as part of the hospice interdisciplinary group (IDG). Document 12: Policy #PC.C90 (no revision date) titled Coordination of Services sub-section three (3) stated in part, “An assigned hospice RN Case Manager coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, and other members of the IDG and non-hospice healthcare providers furnishing services unrelated to the terminal illness.” Clinical Record 3: The hospice benefit election date was 12/21/2023. The patient lived in an Assisted Living Facility (ALF). The initial RN assessment dated 12/21/2023 included a narrative sub-section which stated, “Patient recently had fallen and has skin tears to his LFA (left forearm), R (right) hand, and R (right) knee. He also has DTI (deep tissue injury) to his R (right heels). These will be changed three (3) times weekly/as needed (PRN).” There were no orders on the plan of care that documented who would perform the wound care. Clinical Record 7: The hospice benefit election date was 12/5/2023. The patient lived in an Assisted Living Facility (ALF). The initial RN assessment included a narrative sub-section that stated, “He has wounds to his L knee, L Achilles, and L lateral leg that will be changed three (3) times weekly. There were no orders on the plan of care that documented who would perform the wound care. A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the hospice RN did not coordinate the care of the hospice patients with non-hospice healthcare providers.”

“It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care and ensure hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) records reviewed it was revealed that the hospice agency did not ensure care and services provided to patients and families followed the individualized plan of care established by the hospice IDG. Document 12: Policy #PC.C90 (no revision date) titled Coordination of Services sub-section three (3) stated in part, “An assigned hospice RN Case Manager coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, and other members of the IDG and non-hospice healthcare providers furnishing services unrelated to the terminal illness.” Clinical Record 6: The hospice benefit election date was 11/17/2023. The plan of care dated 11/17/2023, did not contain any orders for disciplines and visit frequencies. The Interdisciplinary Group (IDG) meeting minutes dated 11/20/2023 that documented assignment details stated in part, “RN (no frequency), LPN (two (2) visits weekly), Social Worker (no frequency), Chaplain (no frequency), Hospice aide (two (2) times weekly). The week of 11/19/2023-11/25/2023, the patient received an LPN visit on 11/24/2023. There was no documentation of the one (1) missed LPN visit during that week. Clinical Record 7: The hospice benefit election date was 12/5/2023. There was no documentation of an individualized plan of care. The patent was receiving hospice aide services. The Executive Director (staff) stated in a joint record review and interview on 12/28/2023 that it is the expectation of the care team the hospice aide should visit the patient two (2) times weekly. The week of 12/10/2023-12/16/2023 the patient received one (1) hospice aide visit on 12/13/2023. The record did not contain any documentation of a missed visit. In addition, the RN and the IDG was not updated about the missed hospice aide visit. A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the hospice did not ensure that care and services provided followed an individualized plan of care established by the IDG.”

“It is required that each patient’s individualized written plan of care include 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, document review and interview. In 3 of 14 (21%) records reviewed it was revealed that the hospice agency did not ensure the written plan of care included a detailed statement of the scope and frequency of services necessary to meet the needs of the patient and family. Document 1: Policy #C30 (no revision date), titled Clinical Records sub-section Policy, stated in part, “A clinical record is established and maintained for every patient. The record is complete, promptly, and accurately documented.” Sub-section one (1) stated in part, “Each patient’s clinical record contains: (a) The initial plan of care, (b) updated plans of care.” Clinical Record 5: The hospice benefit election date was 8/17/2023. The plan of care did not contain orders for visit disciplines with scope or frequency of service. The Interdisciplinary Group (IDG) Assessment dated 8/22/2023 had assignment details which stated, “RN (no frequency), LPN (no frequency), Social Worker (no frequency), Chaplain (no frequency), and Hospice aide two (2) times weekly. The patient received RN visits weekly dated 9/14/2023, 9/21/2023, 9/28/2023, 10/12/2023, 10/26/2023, 11/9/2023, and 12/4/2023, and 12/18/2023. Clinical Record 6: The hospice benefit election date was 11/17/2023. The plan of care dated 11/17/2023, did not contain any orders for visit disciplines with frequencies. The Interdisciplinary Group (IDG) Assessment dated 11/20/2023 had assignment details which stated, “RN (no frequency), LPN (two (2) visits weekly), Social Worker (no frequency), Chaplain (no frequency), Hospice aide (two (2) times weekly). The week of 11/19/2023-11/25/2023, the patient received one LPN visit dated 11/24/2023. There was no documentation of the missed LPN visit. Clinical Record 7: The hospice benefit election date was 12/5/2023. There was no documented plan of care. The patient was receiving aide services and there was no documented visit frequency order. The Executive Director (staff 2) stated in a joint record review and interview on 12/28/2023 that it is the expectation of the care team the hospice aide should visit the patient two (2) times weekly. During the week of 12/10/2023-12/16/2023, the patient received one (1) hospice aide visit on 12/13/2023. The record did not contain any documentation of a missed visit. In addition, the RN and the IDG were not updated about the missed hospice aide visit. The record contained a hospice aide care plan dated 12/7/2023, which stated in part, “ Bathroom Assistance, (no frequency), Barrier Products in Use (specify) (no frequency), Incontinent (no frequency) Urinary Cather (specify) no frequency, and Assist with Feeding (no frequency) A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the hospice did not ensure a detailed statement of the scope and frequency of services necessary to meet the needs of the patient and family. was documented on the plan of care.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) records reviewed it was revealed that the hospice agency did not ensure that the plan of care was initiated and reviewed and updated every fifteen (15) calendar days. Document 4: Policy# PC.P50 (no revision date) titled Plan of Care sub-section two (2) stated in part, “The Comprehensive Plan of Care is developed within five (5) days of admission with input from all IDG members.” Clinical Record 2: The hospice benefit election date was 12/16/2023. There was no documentation of an Interdisciplinary Group (IDG) care plan. The plan of care sub-section stated in part, “No plan of care exists.” Clinical Record 3: The hospice benefit election date was 12/21/2023. There was no documentation of an Interdisciplinary Group (IDG) care plan. The plan of care stated in part, “No plan of care exists.” Clinical Record 4: The hospice benefit election date of 7/25/2023 did not have a plan in place for the period of 7/28/2023 -9/8/2023. One problem/goal/intervention was listed on 7/28/2023 and resolved on 7/28/2023, which stated in part, “ deficit related to patient care management.” There were no care plans with problems/goals/or interventions from 7/28/2023 until 9/8/2023 when the following problems and interventions were added, “deficit related to infection, deficit related bowel elimination, and deficit related to dying process, and deficit related to the risk of injury and falls.”, All of the problems and interventions expired on 12/7/2023 when the patient was due for recertification The recertification was not completed in the electronic medical record. The patient had no active care plan. Clinical Record 5: A patient with a hospice benefit election date of 8/17/2023 had a plan of care that did not receive a comprehensive assessment by the RN for twenty-four (24) days from 11/9/2023 to 12/4/2023. There was no documentation that the plan of care was reviewed every 15 days. Clinical Record 7: The hospice benefit election date was 12/5/2023. There was no documentation of an Interdisciplinary Group (IDG) care plan. The plan of care stated in part, “No plan of care exists.” Clinical Record 9: A patient with a hospice benefit election date of 8/16/2023 and a discharge date of 9/5/2023 for an extended prognosis did not have an Interdisciplinary Group (IDG) care plan. Upon discharge, the hospice agency sent a current medication list and provided a care coordination note with the patient’s current physician. Clinical Record 10: The hospice benefit election date was 9/11/2023 and the discharge date was 11/27/2023. The IDT meeting dates documented in the record were 10/17/2023 and 11/28/2023. There was no documentation that the patient was discussed, and the plan of care was reviewed at the IDG meetings held on 9/19/2023, 10/3/2023, 10/31/2023, and 11/14/2023. A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the hospice agency did generate an Interdisciplinary Group (IDG) plan of care and did not contain evidence of the review of the plan of care at IDT meetings.”

“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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) records reviewed where hospice aide services were accepted, it was revealed that the agency did not ensure that there were specific written instructions on the hospice aide care plans, thus leaving the aides to make decisions outside their scope of practice. Document 11: Policy #PC.H25 (no revision date) titled Hospice Aide Assignments and Duties sub-section (1) stated in part, “Hospice aides are assigned to specific patients by a hospice RN that is a member of the interdisciplinary group and follow written patient care instructions in providing care to assigned patients.” Sub-section five (5) stated in part, “The hospice RN is responsible for supervising the hospice aide and prepares written patient care instructions that are patient-specific and not generic.” Sub-section six (6) stated in part, “The hospice aide provides services that are: (a) ordered by the interdisciplinary group, (b) included in the plan of care.” Clinical Record 2: A patient with a hospice benefit election date of 12/16/2023 had a hospice aide care plan dated 12/27/2023 which stated in part, “Ambulatory with Assistance (specify) (no frequency), TPR and BP (no frequency), barrier products in use (specify) (no frequency), Incontinent (specify) (no frequency). Clinical Record 3: A patient with a hospice benefit election date of 12/21/2023 had a hospice aide care plan dated 12/22/2023, which stated in part, “ Bathroom Assistance (no frequency), Barrier Products in Use (specify) (no frequency), Incontinent (no frequency), Urinary Cather (specify) no frequency, and Assist with Feeding (no frequency). Clinical Record 7: A patient with a hospice benefit election date of 12/5/2023 with no documented physician order for visit frequency. The Executive Director (staff 2) stated in a joint record review and interview on 12/28/2023 that it is the expectation of the care team the hospice aide should visit the patient two (2) times per week. During the week of 12/10/2023-12/16/2023, the patient received one (1) hospice aide visit on 12/13/2023. The record did not contain any documentation of a missed visit. The record contained a hospice aide care plan dated 12/7/2023, which stated in part, “Bathroom Assistance (no frequency), Barrier Products in Use (specify) (no frequency), Incontinent (no frequency), Urinary Cather (specify) no frequency, and Assist with Feeding (no frequency). A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the hospice RN did not provide specific written instructions to the hospice aide, as the hospice RN did not assign any frequency of tasks on the hospice aide care plans.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) records reviewed where volunteer services were accepted it was revealed that the hospice agency did not ensure volunteer services were included in the plan of care. Document 5: Policy #PC.P55, (no revision date) titled Plan of Care-Content sub-section one (1) stated in part, “The patient’s plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions.” Sub-section two (2) stated in part “The plan of care must reflect the patient and family goals and interventions based on the problems identified. The plan of care must include (c) A statement detailing the scope and frequency of services necessary to meet the patient’s and family’s needs.” Clinical Record 1: The volunteer plan of care dated 11/8/2023 created by the volunteer coordinator stated in part, “Problems: socialization, emotional support, respite, errand shopping, transportation, and daily living.” Services needed were “Emotional support, bereavement support, practical support, respite care, music, phone calls, letter writing, reading, and meal prep”. The volunteer care plan did not specify any visit frequency for the volunteer to provide services to the patient/family and volunteer services were not ordered on the plan of care. Clinical Record 2: The patient received one (1) volunteer visit on 12/23/2023. There was a volunteer plan of care created by the volunteer coordinator dated 12/19/2023, which stated in part, “Problems: Socialization, emotional support.” Services needed included “Emotional support, bereavement support, and crafts.” The volunteer care plan did not specify any visit frequency for the volunteer to provide services to the patient/family and volunteer services were not ordered on the plan of care. Clinical Record 3: The patient received one (1) volunteer visit on 12/23/2023. There was a volunteer plan of care created by the volunteer coordinator dated 12/22/2023, which stated in part, “Problems: Socialization, emotional support, and daily living.” Services needed included “Emotional support, bereavement support, practical letter writing, reading, and crafts.” The volunteer care plan did not specify any visit frequency for the volunteer to provide services to the patient/family and volunteer services were not ordered on the plan of care. A joint record review and interview with the Clinical Director (staff 1) on 12/27/2023 confirmed the records did not contain any documentation of visit frequency of assigned volunteer services or physician order for visit frequency of volunteer services.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its ordinary course. When making this determination, the physician considers the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. . This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) records reviewed it was revealed that the hospice agency did not ensure the physician written certification of terminal illness contained a narrative statement that considered related diagnosis, current subjective and objective data, current medications, and other information about the medical management of the patient’s condition. Document 8: Policy #PC.10 (no revision date) titled Certification of Terminal Illness sub-section two (2) stated in part, “Content of Certification: The certification must conform to the following requirements: (a) The certification must specify that the individual’s prognosis is six (6) months or less. The physician must consider the following when making the determination: (i) The primary diagnosis, (ii) related diagnosis, (iii) current subjective and injective medical findings, (iv) current medication and treatment orders, and (v) information about the medical management of the patient’s conditions unrelated to the terminal illness.” Sub-section (c) stated in part, “The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six (6) months or less.” Clinical Record 1: The hospice benefit election date was 11/06/23. The verbal Certification of Terminal Illness (CTI) was signed and dated 11/6/2023 and stated in part, “I certify the patient is terminally ill due to Parkinson’s disease with a life expectancy of six (6) months or less if the disease runs its normal course”. However, the record did not contain a narrative certification note that considered the secondary-related diagnosis, current subjective and objective data or information about the medical management of the patient’s condition. The initial RN assessment was completed on 11/6/2023 and stated in part, “Past Medical History: long-term ant-coagulant use, dyslipidemia, hypertensive cardiovascular disease, A-Fib, Sick Sinus Syndrome.” Clinical Record 5: The hospice benefit election date was 8/17/2023. The Recertification of Terminal Illness (CTI) signed and dated 11/11/2023 stated in part, “I certify the (patient) is terminally ill due to Parkinson’s disease with a life expectancy of six (6) months or less if the disease runs its normal course. The record did not contain a written narrative that considered the secondary-related diagnosis with current subjective and objective data or information about the medical management of the patient’s condition. The Initial RN assessment dated 8/17/2023 stated in part, “The patient is alert to self only. She is in a wheelchair and requires hoyer lift assistance. The patient has a stage two (2) on her coccyx that will be changed twice weekly, and she has edema to the left arm.” Clinical Record 14: The hospice benefit election date was 6/20/2023. The Certificate of Terminal Illness (CTI) signed and dated 6/22/2023 stated, “Patient with a history of chronic systolic heart failure, and due to his illness life expectancy is less than six (6) months”. The record did not contain a written narrative statement that considered the secondary-related diagnosis with current subjective and objective data or information about the medical management of the patient’s condition. The Initial RN assessment dated 6/20/2023 stated in part, “Patient has a diagnosis of Congestive Heart Failure (CHF), Acute Osteomyelitis of the left foot with wound and gangrenous toes. He also has a diagnosis of hypertension (HTN) and A-Fib.” A joint record review and interview with the Clinical Director (staff 1) on 12/29/2023 confirmed the Certificate of Terminal Illness (CTI) did not contain a narrative paragraph that included secondary diagnosis or subjective and objective data related to the terminal illness.”

“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: physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) records reviewed it was revealed that the hospice agency did not ensure the clinical record contained physician orders for treatment. Document 1: Policy #C30 (no revision date), titled Clinical Records sub-section Policy, stated in part, “ A clinical record is established and maintained for every patient. The record is complete, promptly, and accurately documented.” Sub-section one (1) stated in part, “Each patient’s clinical record contains: (O) physician’s orders that include medications, dietary information, treatment, and activity orders.” Clinical Record 3: The hospice benefit election date was 12/21/2023. The initial RN assessment on 12/21/2023 subsection titled skin stated “pale.” The narrative sub-section stated, “Patient recently had fallen and has skin tears to his LFA (left forearm), R (right) hand, and R (right) knee. He also has DTI (deep tissue injury) to his R (right heels). These will be changed three (3) times weekly/as needed (PRN).” The clinical record did not contain any physician orders for wound care. Clinical Record 7: The hospice benefit election date was 12/5/2023. The initial comprehensive RN assessment narrative stated, “Wound care to L knee three (3) times weekly/as needed (PRN). Cleanse with NS, apply Medi honey adaptic, cover with non-stick gauze, and wrap with Kerlix/tape. There were no physician orders for wound care in the record. A joint record review and interview with the Clinical Director (staff 1) on 12/28/2023 confirmed the records did not contain physician orders for wound care.”