Season’s Hospice, Inc.

“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 treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile and plan of care for the palliation and management of the terminal illness. Clinical Record 2: The date of election was 11/20/2023. The Medication Profile printed on 11/11/2024 revealed Melatonin 10mg orally at bedtime, Mirtazapine 7.5mg orally at bedtime, and Tylenol 325mg 2 tablets orally every 4 hours as needed for pain. During the Home Visit (Clinical Record 2) on 11/12/2024 with the Hospice Aide (Personnel Record 11), the facility medication record lacked the Melatonin, Mirtazapine, and as needed Tylenol. The facility LPN reported that the Melatonin was discontinued on 08/27/2024, the Mirtazapine was discontinued on 09/18/2024, and the Tylenol 325mg 2 tablets every 4 hours was not found within the facility orders. Clinical Record 3: The date of election was 08/02/2024. The Medication Profile printed on 11/11/2024 revealed Albuterol Sulfate 2.5mg/3ml (0.083%) one Nebu Soln inhalation every 6 hours as needed for SOB or wheezing and Chlorhexidine Gluconate 0.12% 5ml oropharyngeal twice a day. During the Home Visit (Clinical Record 3) on 11/12/2024 with the Medical Social Worker (Personnel Record 8), the facility medication record lacked the Albuterol Sulfate and Chlorhexidine Gluconate. The facility RN reported that the Chlorhexidine Gluconate was discontinued on 07/28/2024, and the Albuterol Sulfate was not found within the facility orders. During a joint record review and interview on 11/12/2024, the Clinical Director confirmed that there was no documented evidence that medication reconciliation was completed, and medications updated to the medication profile and plan of care.”

“It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that medical social services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services. Clinical Record 16: The patient’s date of election was 02/14/2023. The Plan of Care Order dated 02/14/2023 for the benefit period 02/14/2023-05/14/2023 and 05/03/2023 for the benefit period 05/15/2023-08/12/2023 documented “Medical Social Worker 1/mo for 3/mo with 3 PRN for psychosocial needs.” The IDG Meeting note dated 05/31/2023 documented “Medical Social Worker/eff 5/19 0x month and 3 PRN psychosocial support.” There was no documented evidence that social work visits were made 1 x monthly between 03/01/2023 through 05/19/2023. Clinical Record 18: The patient’s date of election was 02/21/2023. The Plan of Care Order dated 02/21/2023 for the benefit period 02/21/2023-05/21/2023 documented “Medical Social Worker 1/mo for 3/mo with 3 PRN for change in condition/request.” The Missed Visit Form (MSW Visit) dated 03/22/2023 documented, “Pt is in the shower at the time of visit.” The Missed Visit Form (MSW Visit) dated 05/10/2023 documented, “Pt is in the salon getting her hair done at attempted visit, sw will try again.” There was no additional evidence that any other attempts were made for the visits. There was no documented evidence of physician orders cancelling the social worker visits for March or May 2023. There was no documented evidence that social work visits were made 1 x monthly for March or May 2023. During a joint record review and an interview on 11/14/2024, the Executive Director confirmed that there was no documented evidence that social work services were provided during the times identified. During a joint record review and an interview on 11/14/2024, the Clinical Director confirmed that there was no documented evidence that social work services were provided during the times identified.”

“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 and interview. In 1 of 19 (5%) clinical record review revealed the agency did not ensure physician orders for volunteer visits. Clinical Record 2: The patient’s date of election was 11/20/2023. Volunteer visit notes dated 02/05/2024 and 02/12/2024 were present in the record. The record lacked evidence of a physician’s orders for the volunteer visit. During a joint record review and interview on 11/13/2024, the Clinical Director confirmed that the records lacked evidence of physician’s orders for the volunteer visits.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for patients transferred to a Medicare/Medicaid certified facility reviewed revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. Clinical Record 15: The patient’s care was transferred to another Hospice provider on 10/10/2024. The record lacked evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 11/13/2024, the Clinical Director confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid certified facility.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 16: The patient’s election of benefits was 02/14/2023 and discharged due to revocation on 07/15/2024. The discharge summary dated 07/15/2024 lacked documentation that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 11/13/2024, the Clinical Director confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by interview and observation. In 2 of 4 (50%) clinical records of patients residing in a Skilled Nursing Facility (SNF) reviewed during a home visit revealed the organization did not ensure the Interdisciplinary Group (IDG) provided the SNF with the physician certification and recertification of the terminal illness. Home Visit 1: The patient’s date of election was 11/20/2024. During the Home Visit (Clinical Record 2) on 11/12/2024 with the Hospice Aide (Personnel Record 11), the patient’s hospice binder at the SNF was reviewed. There was no documented evidence of the physician certification and recertification of the terminal illness in the binder. Home Visit 2: The patient’s date of election was 08/02/2024. During the Home Visit (Clinical Record 3) on 11/12/2024 with the Medical Social Worker (Personnel Record 8), the patient’s hospice binder at the SNF was reviewed. There was no documented evidence of the physician certification and recertification of the terminal illness in the agency binder. During a joint record review and an interview on 11/12/2024, the Executive Director confirmed there was no documented evidence of the physician certification and recertification of the terminal illness in the patient’s hospice binder at the SNF.”