Refuge Care Hospice

“It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse events. This standard was not met as evidenced by document review and interview. A review of the hospice’s 2022 and 2023 QAPI documentation revealed raw data was documented each quarter from chart audits, patient infections, internal patient surveys, and adverse events, but there was no trending or analysis of the data collected. In addition, it was confirmed during an interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/03/2024 and his conversation with the outgoing Administrator that no QAPI Meetings were documented for 2022 or 2023 due to the belief that they were not required during the COVID Public Health Emergency. This standard was not met after a review of the hospice’s 2022 and 2023 QAPI documentation. In addition, it was confirmed during an interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/03/2024 and his conversation with the outgoing Administrator that no QAPI Meetings were documented for 2022 or 2023 due to the belief that they were not required during the COVID Public Health Emergency. Raw data was documented each quarter from chart audits, patient infections, internal patient surveys, and adverse events, but there was no trending or analysis of the data collected.”

“It is required that the documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served, represent the internal needs of the organization, and reflect the scope, complexity, and past performance of the hospice’s services and operations. This standard was not met as evidenced by document review and interview. A review of the hospice’s 2022 and 2023 QAPI documentation and interviews with both the Administrator/Patient Care Coordinator and the Assistant Administrator, revealed that there were no documented QAPI Performance Improvement Projects (PIPs) for 2022 or 2023. It was confirmed during an interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/03/2024 and his conversation with the outgoing Administrator that no Performance Improvement Projects (PIPs) were documented for 2022 or 2023 as she thought no PIPs were required during the COVID Public Health Emergency. No documented COVID-19 pandemic PIP was found in the QAPI documentation either. There have not yet been any QAPI PIPs initiated for 2024. The standard was not met after a review of the hospice’s 2022 and 2023 QAPI documentation and interviews with both the Administrator/Patient Care Coordinator and the Assistant Administrator, which revealed that there were no documented QAPI Performance Improvement Projects (PIPs) for 2022 or 2023. It was confirmed during an interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/03/2024 and his conversation with the outgoing Administrator that no Performance Improvement Projects (PIPs) were documented for 2022 or 2023 as she thought no PIPs were required during the COVID Public Health Emergency. No documented COVID-19 pandemic PIP was found in the QAPI documentation either. There have not yet been any QAPI PIPs initiated for 2024.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 10 of 14 (71%) clinical records reviewed revealed the agency did not ensure that there was monthly documented LPN supervision by the RN per agency policy. The policy (Revised 10/12/2018), titled “Hospice Nursing Care Policy” (No H: 2-004.1), read in part, “...When nursing services are delegated to a licensed vocational/practical nurse (LVN/LPN) ... The RN makes at least monthly home visits and documents every 30 days that the LVN is routinely providing nursing services in accordance with the patient’s plan of care.” The agency policy (Review/Revised 10/12/2018), titled “Responsibilities/Supervision of Clinical Services” (Policy No. H: 3-003) included in part that “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocation nursing services... Supervisory contacts and visits will be documented, dated, and signed by the supervising professional.” Clinical Record 1: The patient elected the hospice benefit on 11/27/2023. The Plan of Care Order dated 11/27/2023 effective 11/27/2023 to 02/24/2024) and the Plan of Care Order dated 03/01/2024 effective 02/25/2024 to 05/24/2024 included orders for the nurse to visit the patient one to two times a week. Licensed Practical Nurse (LPN) visits were documented on 02/12/2024, 02/26/2024, 03/11/2024, 03/25/2024, and 04/08/2024. There was no documentation of LPN supervision by the Registered Nurse found in the clinical record as per policy requirement. Clinical Record 2: The patient elected the hospice benefit on 01/02/2024. A Plan of Care Order dated 01/09/2024 effective 01/02/2024 to 03/31/2024 and a Plan of Care Order dated 04/02/2024 effective 04/01/2024 to 06/29/2024 included orders for the nurse to visit the patient one to two times a week. Licensed Practical Nurse (LPN) visits were documented on 02/12/2024, 02/14/2024 02/26/2024, 03/11/2024, 03/25/2024, 04/08/2024, and 04/22/2024. There was no documentation of LPN supervision by the Registered Nurse found in the clinical record as per policy requirement. Clinical Record 3: The patient elected the hospice benefit on 09/15/2023. A Plan of Care Order dated 12/27/2023 effective 12/14/2023 to 03/12/2024 and a Plan of Care Order dated 03/07/2024 effective 03/13/2024 to 05/11/2024 included orders for the nurse to visit the patient one to two times a week. Licensed Practical Nurse visits were documented 02/12/2024, 02/26/2024, 03/11/2024, 03/25/2024, and 04/08/2024. There was no documentation of LPN supervision by the Registered Nurse found in the clinical record as per policy requirement. Clinical Record 4: The patient elected the hospice benefit on 01/030/2024. A Plan of Care Order dated 01/30/2024 effective 01/30/2024 to 04/28/2024 and a Plan of Care Order dated 04/23/2024 effective 04/29/2024 to 07/27/2024 included orders for the nurse to visit the patient one to two times weekly. Licensed Practical Nurse visits were documented 02/05/2024, 02/19/2024, 03/04/2024, 03/18/2024, 04/01/2024, and 04/15/2024. There was no documentation of LPN supervision by the Registered Nurse found in the clinical record as per policy requirement. Clinical Record 5: The patient elected the hospice benefit on 11/14/2023. A Plan of Care Order dated 11/14/2023 effective 11/14/2023 to 02/11/2024 and a Plan of Care Order dated 02/06/2024 effective 02/12/2024 to 05/11/2024 included orders for the nurse to visit the patient one to two times weekly. Licensed Practical Nurse visits were documented 02/15/2024, 02/27/2024, 03/12/2024, 03/26/2024, 04/12/2024, and 04/23/2024. There was no documented LPN supervision by the Registered Nurse found in the clinical record as per policy requirement. Clinical Record 6: The patient elected the hospice benefit on 01/25/2024. A Plan of Care Order dated 101/25/2024 effective 01/25/2024 to 04/23/2024 and a Plan of Care Order dated 04/09/2024 effective 04/24/2024 to 07/22/2024 included orders for the nurse to visit the patient one to two times weekly. Licensed Practical Nurse visits were documented 02/05/2024, 02/19/2024, 03/04/2024, 03/18/2024, 04/01/2024, 04/15/2024 and 04/29/2024. There was no documented LPN supervision by the Registered Nurse as per policy requirement. Clinical Record 7: The patient elected the hospice benefit on 09/14/2023. A Plan of Care Order dated 12/14/2023 effective 12/13/2023 to 03/11/2024 and a Plan of Care Order dated 03/02/2024 effective 03/12/2024 to 05/10/2024 included orders for the nurse to visit the patient one to two times weekly. Licensed Practical Nurse visits were documented 02/05/2024, 02/19/2024, 03/04/2024, 03/19/2024, 04/02/2024, 04/16/2024, and 04/30/2024. There was no documented LPN supervision by the Registered Nurse as per policy requirement. Clinical Record 8: The patient elected the hospice benefit on 09/15/2023. A Plan of Care Order dated 12/27/2023 effective 12/14/2023 to 03/12/2024 and a Plan of Care Order dated 03/07/2024 effective 03/13/2024 to 05/11/2024 included orders for the nurse to visit the patient one to two times weekly. Licensed Practical Nurse visits were documented 02/12/2024, 02/26/2024, 03/11/2024, 03/25/2024, and 04/08/2024. There was no documented LPN supervision by the Registered Nurse as per policy requirement. Clinical Record 10: The patient elected the hospice benefit on 09/28/2023. A Plan of Care Order dated 09/28/2023 effective 09/28/2023 to 12/26/2023 and a Plan of Care Order dated 12/27/2023 effective 12/27/2023 to 03/25/2024 included orders for the nurse to visit the patient one to two times weekly. Licensed Practical Nurse visits were documented 01/03/2024, 01/17/2024, 01/31/2024, 02/14/2024, 02/28/2024, and 03/13/2024. There was no documented LPN supervision by the Registered Nurse as per policy requirement. Clinical Record 12: The patient elected the hospice benefit on 07/20/2023 and discharged 10/26/2023. A Plan of Care Order dated 07/20/2023 effective 07/20/2023 to 10/17/2023 and a Plan of Care Order dated 10/17/2023 effective 10/18/2023 to 01/15/2024 included orders for the nurse to visit the patient one to two times weekly. Licensed Practical Nurse visits were documented 10/12/2023, 10/26/2023, 11/08/2023, 11/22/2023, and 12/06/2023. There was no documented LPN supervision by the Registered Nurse as per policy requirement. During a joint record review and interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/01/2024 confirmed that there were no LVN supervisory visits documented. He confirmed he was unaware of the agency’s policy indicating the required frequency of LPN supervision to be documented every 30 days. He just began Administrator training at the end of September 2023 and assumed the role of Patient Care Coordinator 12/22/2023.”

“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 9 of 10 (90%) clinical records reviewed in which hospice aide services were provided revealed the agency did not ensure that the Registered Nurse provided complete instructions to the hospice aide for interventions listed in the Aide Plan of Care. The policy (Revised 10/12/2018), titled “Hospice Aide Services” (Policy No. H: 2-005.1) included in part, “Services provided by an aide could include bathing, shampoo, range of motion activities, dry dressing changes, assisting the patient to the bathroom, use of commode or bedpan, assisting with meal preparation, feeding the patient, light housekeeping, and/or linen changes. These activities, in accordance with the plan of care and physician’s orders ... will be assigned and supervised by a hospice registered nurse... The need for hospice aide services will be identified by the RN Case Manager and included in the interdisciplinary plan of care... Hospice aide assignments, plan of care, and intervention will be documented and included in the patient’s clinical record. Hospice aide duties include assisting with personal hygiene, assisting with ambulation, and exercise...reporting changes in the patient’s condition and needs ... Hospice aides will document care provided in accordance with the hospice aide assignment.” Clinical Record 1: The patient elected the hospice benefit on 11/27/2023 with the primary diagnosis of Alzheimer’s. The Plan of Care dated 11/27/2023 effective 11/27/2023 to 02/24/2024) and the Plan of Care Order dated 03/01/2024 effective 02/25/2024 to 05/24/2024 included orders for the hospice aide to visit the patient one to three times a week. The Aide Care Plan dated 11/27/2023 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when they should notify the Registered Nurse. Additionally, the care plan included the instructions for the following interventions to be performed every visit, pt/cg request: complete shower, shampoo hair, peri care, foot care, nail care, oral hygiene/denture care, come hair, skincare, and to assist the patient with dressing. The care plan also included interventions for another type of bath - complete bed bath, shave the patient, and provide incontinence care “PRN, pt/cg request” for an Alzheimer’s patient residing in a nursing facility. Clinical Record 2: The patient elected the hospice benefit on 01/02/2024. A Plan of Care Order dated 01/09/2024 effective 01/02/2024 to 03/31/2024 and a Plan of Care Order dated 04/02/2024 effective 04/01/2024 to 06/29/2024 included orders for the hospice aide to visit the patient one to three times a week. The Aide Care Plan dated 01/02/2024 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when they should notify the Registered Nurse. Clinical Record 3: The patient elected the hospice benefit on 09/15/2023 with atherosclerotic heart disease. The patient was unable to sign her own hospice consent due to cognitive issues. A Plan of Care Order dated 12/27/2023 effective 12/14/2023 to 03/12/2024 and a Plan of Care Order dated 03/07/2024 effective 03/13/2024 to 05/11/2024 included orders for the hospice aide to visit the patient one to three times a week. The Aide Care Plan dated 12/14/2023 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when they should notify the Registered Nurse. Additionally, the case plan included the following interventions to be completed “every visit, pt/cg request”: complete shower, shampoo hair, peri care, foot care, nail care, oral hygiene/denture care, comb hair, skincare, and assist the patient in dressing. The care plan also included an intervention for another type of bath - a bed bath, shave, and incontinence care “PRN, pt/cg request” for a patient with cognitive issues residing in a nursing facility. Clinical Record 4: The patient elected the hospice benefit on 01/030/2024. A Plan of Care Order dated 01/30/2024 effective 01/30/2024 to 04/28/2024 and a Plan of Care Order dated 04/23/2024 effective 04/29/2024 to 07/27/2024 included orders for the hospice aide to visit the patient one to three times a week. The Aide Care Plan dated 01/30/2024 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when they should notify the Registered Nurse. Clinical Record 6: The patient elected the hospice benefit on 01/25/2024. A Plan of Care Order dated 01/25/2024 effective 01/24/2024 to 04/23/2024 and a Plan of Care Order dated 004/09/2024 effective 04/24/2024 to 07/22/2024 included orders for the hospice aide to visit the patient one to three times a week. The Aide Care Plan dated 01/25/2024 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when they should notify the Registered Nurse. During the Admission visit, the Registered Nurse documented a right heel unstageable pressure injury wound measuring 3.5 x 4.5 with instruction paint the wound with betadine and cover with Mepilex dressing every 72 hours. Then, on 02/02/2024, there was an order documented to cleanse wound to right heel with wound cleanser and pat dry. Apply Medihoney to wound bed and cover with border form dressing daily and as needed for soiled dressing. The Aide Care Plan listed under functional limitations that the patient had a wound to the right heel but did not include any instruction to notify the RN if the dressing was loose, soiled, or wet. Clinical Record 7: The patient elected the hospice benefit on 09/14/2023. A Plan of Care Order dated 12/14/2023 effective 12/13/2023 to 03/11/2024 and a Plan of Care Order dated 03/02/2024 effective 03/12/2024 to 05/10/2024 included orders for the hospice aide to visit the patient one to three times a week. The Aide Care Plan dated 03/12/2024 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when they should notify the Registered Nurse. Clinical Record 8: The patient elected the hospice benefit on 09/15/2023. A Plan of Care Order dated 12/27/2023 effective 12/14/2023 to 03/12/2024 and a Plan of Care Order dated 03/07/2024 effective 03/13/2024 to 05/11/2024 included orders for the hospice aide to visit the patient one to three times a week. The Aide Care Plan dated 12/14/2023 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when they should notify the Registered Nurse. Clinical Record 11: The patient elected the hospice benefit on 11/17/2022 and was discharged for an extended prognosis on 09/29/2023. A Plan of Care Order dated 05/16/2023 effective 05/16/2023 to 07/14/2023 and a Plan of Care Order dated 07/25/2023 effective 07/15/2023 to 09/12/2023 included orders for the hospice aide to visit the patient one to two times per week. The Aide Plans of Care dated 07/15/2023 and 09/13/2023 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when the aide should notify the Registered Nurse. Clinical Record 13: The patient elected the hospice benefit on 08/08/2023 and died on hospice services on 02/09/2024. A Plan of Care Order dated 08/28/2023 effective 08/28/2023 to 11/25/2023 and a Plan of Care Order dated 11/28/2023 effective 11/26/2023 to 02/23/2024 included orders for the hospice aide to visit the patient one to three times a week. The Aide Plan of Care dated 11/26/2023 instructed the aide to obtain a temperature, pulse, respiratory rate, and blood pressure at each visit. No parameters for the vital signs were provided for the aide regarding when the Registered Nurse should be notified. During an interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/01/2024 and 05/02/2024, it was determined that the current process and set up of the Aide Care Plans currently did not include any vital sign parameters for the aide to know when to contact the nurse about any vital sign readings.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 10 (40%) clinical records reviewed in which hospice aide services were provided revealed the agency did not ensure that the aide notified the registered nurse when the plan of care was not followed or there were changes in the patient. The policy (Revised 10/12/2018), titled “Hospice Aide Services” (Policy No. H: 2-005.1) included in part, “Services provided by an aide could include bathing, shampoo, range of motion activities, dry dressing changes, assisting the patient to the bathroom, use of commode or bedpan, assisting with meal preparation, feeding the patient, light housekeeping, and/or linen changes. These activities, in accordance with the plan of care and physician’s orders ... will be assigned and supervised by a hospice registered nurse... The need for hospice aide services will be identified by the RN Case Manager and included in the interdisciplinary plan of care... Hospice aide assignments, plan of care, and intervention will be documented and included in the patient’s clinical record. Hospice aide duties include assisting with personal hygiene, assisting with ambulation, and exercise...reporting changes in the patient’s condition and needs ... Hospice aides will document care provided in accordance with the hospice aide assignment...” Clinical Record 1: The patient elected the hospice benefit on 11/27/2023. The Plan of Care Order dated 11/27/2023 effective 11/27/2024 to 02/24/2024 and the Plan of Care Order dated 03/01/2024 effective 02/25/2024 to 05/24/2024 included orders for the hospice aide to visit the patient one to three times a week. The aide noted that the complete bed bath and shave were refused during the visits documented on 02/05/2024, 02/08/2024, 02/12/2024, 02/15/2024, 02/19/2024, 02/22/2024, 02/26/2024, 02/29/2024, 03/04/2024, 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, and 03/25/2024. During the aide visits on 03/28/2024 and 04/01/2024, it was documented that the patient refused a complete shower, shampooing hair, and a shave. On 04/11/2024, the aide documented every intervention as refused. In the comment section, the aide noted, “Pt had a visitor.” On 04/15/2024, no vital signs were documented. On 04/18/2024, the aide documented that the patient refused a shampoo, shave, and complete shower. There was no evidence that the aide notified the registered nurse when the aide care plan was not followed. Clinical Record 3: The patient elected the hospice benefit on 09/15/2023. A Plan of Care Order dated 12/27/2023 effective 12/14/2023 to 03/12/2024 and a Plan of Care Order dated 03/07/2024 effective 03/13/2024 to 05/11/2024 included orders for the hospice aide to visit the patient one to three times a week. During the aide visits documented 02/05/2024, 02/08/2024, 02/12/2024, 02/15/2024, 02/19/2024, 02/22/2024, 02/26/2024, 02/29/2024, 03/04/2024, 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, 03/25/2024, 03/28/2024 noted that the patient refused a complete bed bath and shave. On 04/01/2024, the aide documented during her visit that the patient refused a complete shower, shampoo, and a shave. During the aide visit documented on 04/04/2024, all the interventions were marked as refused except for obtaining the patient’s vital signs. The aide included “pt refused to have any care.” On 04/11/2024, the aide documented all interventions as refused except for vital signs and noted, “pt refused shower and bed bath due to having an earache.” There was no documented evidence that the hospice aide notified the registered nurse when the aide care plan was not followed or when the patient complained of earache pain. Clinical Record 7: The patient elected the hospice benefit on 09/14/2023. A Plan of Care Order dated 12/14/2023 effective 12/13/2023 to 03/11/2024 and a Plan of Care Order dated 03/02/2024 effective 03/12/2024 to 05/10/2024 included orders for the hospice aide to visit the patient one to three times a week. The hospice aide documented on 03/14/2024 that the patient refused a shampoo and shower. On 03/18/2024, the aide noted that the patient refused a shave and bed bath. There was no evidence that the hospice aide had notified the registered nurse that the aide’s care plan had not been followed. Clinical Record 8: The patient elected the hospice benefit on 09/15/2023. A Plan of Care Order dated 12/27/2023 effective 12/14/2023 to 03/12/2024 and a Plan of Care Order dated 03/07/2024 effective 03/13/2024 to 05/11/2024 included orders for the hospice aide to visit the patient one to three times a week. During the aide visits documented 02/05/2024, 02/08/2024, 02/12/2024, 02/15/2024, 02/19/2024, 02/22/2024, 02/26/2024, 02/29/2024, 03/04/2024, 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, 03/25/2024, 03/28/2024 noted that the patient refused a complete bed bath and shave. There was no evidence that the hospice aide notified the registered nurse that the aide’s care plan had not been followed. Clinical Record 13: The patient elected the hospice benefit on 08/08/2023 and died on hospice services on 02/09/2024. A Plan of Care Order dated 08/28/2023 effective 08/28/2023 to 11/25/2023 and a Plan of Care Order dated 11/28/2023 effective 11/26/2023 to 02/23/2024 included orders for the hospice aide to visit the patient one to three times a week. The hospice aide documented on 02/01/2024, 02/05/2024, and 02/08/2024 that the patient refused the shower, shampoo, and shave. There was no documented evidence that the aide notified the registered nurse that the aide’s care plan had not been followed. After a joint clinical record review and interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/01/2024, 05/02/2024, and 05/03/2024, it was confirmed that there was no documentation in the clinical record that the aide notified the RN when the aide did not follow the care plan as written.”

“It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards, and it includes the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, and procedures to be followed in an emergency and/or following the death of a patient. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) volunteer files reviewed revealed the agency did not ensure that there was documented volunteer orientation. Policy No. H: 3-012) read in part that “...Volunteers attend an orientation program specific to hospice services and the jobs/tasks to be performed. The orientation will be consistent with accepted standards of hospice practice and include: duties to be performed, associated responsibilities related to the tasks, identification of the person the volunteer reports to, persons to contact for assistance and instruction, hospice goals, service and philosophy ... family dynamics, coping mechanisms,, and psychological issues surrounding terminal illness, death and bereavement, procedures to be followed in the event of an emergency or following the death of a patient ...” Personnel Record 9: The Volunteer with the date of hire of 08/09/2023 did not have any documented evidence of having received orientation in her personnel file. During an interview with the Assistant Administrator/Volunteer Coordinator (Personnel Record 2) on 05/03/2024, she confirmed that the volunteer did not have any documented orientation in the personnel file.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. During a review of Volunteer documentation and an interview with the Assistant Administrator/Volunteer Coordinator, it was revealed the agency had no documented efforts to recruit volunteers or retain volunteers. An interview with the Assistant Administrator/Volunteer Coordinator (Personnel Record 2) confirmed that no documentation could be found regarding the recruitment or retention of volunteers. She assumed the role as of 11/15/2023. During a review of Volunteer documentation and an interview with the Assistant Administrator/Volunteer Coordinator, it was revealed the agency had no documented efforts to recruit volunteers or retain volunteers. An interview with the Assistant Administrator/Volunteer Coordinator (Personnel Record 2) confirmed that no documentation could be found regarding the recruitment or retention of volunteers. She assumed the role as of 11/15/2023.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of Volunteer documentation for the last quarter of 2023 and the first quarter of 2024 revealed during September and October 2023, there was documentation that volunteers provided 5.8% of the total patient care hours. However, in 2024, the volunteer percentage dropped below 5%. This was confirmed during an interview with the Assistant Administrator/Volunteer Coordinator (Personnel Record 2) on 05/02/2024. She assumed the role of Volunteer Coordinator on 11/15/2023. She stated they had an active volunteer, but the volunteer had not worked recently due to outside obligations - although she was still considered an active volunteer. This standard was not met after a review of Volunteer documentation for the last quarter of 2023 and the first quarter of 2024. During September and October 2023, there was documentation that volunteers provided 5.8% of the total patient care hours. However, in 2024, the volunteer percentage dropped below 5%. This was confirmed during an interview with the Assistant Administrator/Volunteer Coordinator (Personnel Record 2) on 05/02/2024. She assumed the role of Volunteer Coordinator on 11/15/2023. She stated they had an active volunteer, but the volunteer had not worked recently due to outside obligations - although she was still considered an active volunteer.”

“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, document review, and interview. In 12 out of 14 (86%) clinical records reviewed revealed the agency did not ensure the certifications and recertifications of the terminal illness were signed in accordance with agency policy. Physician Services - Medical Director Policy No. H:2-013.1 “...Certifying that the patient meets the medical criteria for hospice admission based upon available diagnostic and prognostic indicators, related diagnosis, if any, current subjective and objective e medical findings, current mediation and treatment orders ... Providing written certification of the terminal illness including a short clinical narrative for all initial and subsequent benefit periods. Will be provided that a face-to-face encounter visit is performed with the patient prior to their and subsequent benefit periods by the Medical Director or nurse practitioner. Re-certifying patients, as appropriate, for continuation of Medicare Hospice Benefit .... providing evidence of progression of the end-stage disease process...” Certification of Terminal Illness Policy No. H: 2-025.1 “.... When certifying the patient as terminally ill, the hospice Medical Director must consider at least the diagnosis of the terminal condition of the patient ... and current relevant information supporting the diagnosis ...If written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care... At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient’s medical record ... A verbal or written certification statement must be obtained from the Medical Director. no more than two (2) weeks prior or two (2) calendar days after the first day of each period... ...The hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the third benefit period recertification and within 30 days prior to each subsequent recertification period. All physician certification and authorization for hospice services and the certification of terminal illness forms will be filed in the patient’s permanent clinical record.... Tools such as the fiscal intermediary’s Local Coverage Determinations, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis....” Clinical Record 2: The patient elected the hospice benefit on 01/02/2024. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 04/01/2024 through 06/29/2024 was not found documented in the clinical record. There was a place holder entry where the CTI for benefit period two that read “not yet started.” Clinical Record 3: The patient elected the hospice benefit on 09/15/2023. The hospice medical director’s written certification of terminal illness (CTI) for the first certification period beginning 09/15/2023 through 12/13/2023 was dated 09/15/2023 but not signed until 10/03/2023 - eighteen days after the beginning of the certification period. There was no documented verbal certification for benefit period one. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 12/14/2023 through 03/12/2024 was dated 12/12/2023 but not signed until 01/02/2024 - nineteen days after the beginning of the certification period. There was no documented verbal certification for benefit period two. The CTI for the third benefit period beginning 03/13/2024 through 05/11/2024 was dated 02/26/2024 and signed 02/27/2024, however the benefit period listed on the CTI form was 12/14/2023 to 03/12/2024 and not the correct dates of 03/13/2024 to 05/11/2024. Clinical Record 4: The patient elected the hospice benefit on 01/30/2024. The hospice medical director’s written certification of terminal illness (CTI) for the first certification period beginning 01/30/2024 through 04/28/2024 was dated 01/30/2024 but not signed until 02/08/2024 - nine days after the beginning of the certification period. There was no documented verbal certification for benefit period one. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 04/29/2024 through 07/27/2024 was dated and signed 04/18/2024. However, the CTI form included the wrong benefit period dates and instead had the dates of 01/30/2024 to 04/28/2024 and not the correct dates of 04/29/2024 to 07/27/2024. The second benefit period CTI narrative read “Off Eliquis for 2 weeks. The bleeding stopped since Eliquis. They understand risks of stroke but have decided to stop given recurrent bleeding. Wearing SCDs while in recliner so edema is improved, and pain improved. No falls. dyspnea on exertion, sleeping in chair. Good appetite.” The terminal diagnosis of congestive heart failure nor any related conditions were not included in the physician narrative nor was any object data such as Palliative Performance Score, weight, mid-arm circumference, dependence in Activities of Daily Living, New York Heart Association Class, oxygen needs, sleep, or appetite. Clinical Record 5: The patient elected the hospice benefit on 11/14/2023. The hospice medical director’s written certification of terminal illness (CTI) for the first certification period beginning 11/14/2023 through 02/11/2024 was dated 11/14/2023 but not signed until 11/19/2023 - five days after the beginning of the certification period. There was no documented verbal certification for benefit period one. Clinical Record 6: The patient elected the hospice benefit on 01/25/2024. The hospice medical director’s written certification of terminal illness (CTI) for the first certification period beginning 01/25/2024 through 04/23/2024 was dated 01/25/2024 but not signed until 02/08/2024 - fourteen days after the beginning of the certification period. There was no verbal certification documented for benefit period one. The physician’s narrative for the second benefit period beginning 04/24/2024 through 07/22/2024 read, “Wound on heel continues to heal. Continuing wound care. blood sugars continue to run in the 200s to 400s with maximal oral medical therapy. Patient continues to decline insulin for better blood glucose control. No new issues.” The terminal diagnosis of Alzheimer’s nor any related conditions were not included in the physician narrative nor was any objective data such as Palliative Performance Score, weight, mid-arm circumference, dependence in Activities of Daily Living, FAST score, incontinence, sleep, or appetite. Clinical Record 7: The patient elected the hospice benefit on 09/14/2023. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 12/13/2023 through 03/11/2024 was signed and dated on 11/30/2023. However, the CTI form included the wrong benefit period dates and instead had the dates of 09/14/2023 to 12/12/2023. The second benefit period narrative read “Patient has new ulceration of scrotum. Treated with topical cream. Patient does have pain medication ordered PRN but does not receive it from nursing facility when requested despite multiple requests. Hospice staff has requested facility staff to administer pain medication when requested multiple times.” The hospice medical director’s written certification of terminal illness (CTI) for the third certification period beginning 03/12/2024 through 05/10/2024 was not found documented in the clinical record. There was a place holder entry where the CTI for benefit period three that read “not yet started.” The terminal diagnosis of end-stage renal disease nor any related conditions were not included in the physician narrative nor any objective data such as stage of kidney disease, Palliative Performance Score, weight, mid-arm circumference, dependence in Activities of Daily Living, sleep, or appetite. BP 1 CTI 9/14 FOR BP 9/14 - 12/12 (Signed 9/14) “...h/o CKD stage IV, h/o bladder cancer with urostomy, advanced Alzheimer’s, recurrent UTIs, HTN, HLD admitted to LTC facility. He was admitted to hospice services followed by increased UTIs, worsening cognition, increased falls and hip fracture, and advancing renal dysfunction. Requires assistance with all ADLs and IADLs intermittently due to recurrent episodes of severe confusion. He had experienced significant decline prior to admission.” Clinical Record 9: The patient elected the hospice benefit on 05/26/2023. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 08/24/2023 through 11/21/2023 was dated 08/09/2023 but not signed until 09/07/2023- fourteen days after the beginning of the certification period. There was no documented verbal certification for benefit period two. The physician’s narrative for the second benefit period CTI read “”A&Ox2 person and place, +3 edema in LLE and 2+ edema RLE, pitting edema BLE, redness under bilat breast, CTA throughout, incontinence of B&B, increased weakness with ambulation difficulty and limited mobility, poor balance, chairbound, utilizing wc, x1 assist with ADLs, increased confusion, routine Norco is effective pain management, splint on L arm from injury fall. She is declining with a life expectancy of less than 6 months. She is appropriate for hospice care.” The terminal diagnosis of Alzheimer’s nor any related conditions were not included in the physician narrative nor was any objective data such as Palliative Performance Score, weight, mid-arm circumference, or FAST score, The certification for the third benefit period beginning 11/22/2023 through 01/20/2024 was dated 11/14/2024 but not signed until 12/12/2023 - twenty days after the beginning of the third certification period. There was no verbal certification for benefit period three. The hospice medical director’s written certification of terminal illness (CTI) for the fifth certification period beginning 03/21/2024 through 05/19/2024 was not found documented in the clinical record. There was a place holder entry where the CTI for benefit period five that read “not yet started.” Clinical Record 10: The patient elected the hospice benefit on 09/28/2023. The hospice medical director’s written certification of terminal illness (CTI) for the first certification period beginning 08/28/2023 through 12/26/2023 was signed and dated on 10/10/2023 - forty-three days after the beginning of the certification period. There was no verbal certification documented. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 12/27/2023 through 102/25/2024 was signed and dated on 01/02/2024 - six days after the beginning of the certification period. There was no verbal certification documented. Clinical Record 11: The patient elected the hospice benefit on 11/17/2022 and was discharged for extended prognosis on 09/29/2023. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 02/15/2023 through 05/15/2023 was not found documented in the clinical record. There was no verbal certification documented for the second certification period. CTI BP 3 5/16/2023 - 7/14/2023 “She is an elderly female patient who lives at home. She continues to be extremely confused and needs frequent redirection. She is maintaining her weight. She is incontinent of bowel and bladder. Appetite is fair. She has a slow, unsteady gain and requires assistance. She needs assist with all of her ADLs. She is having some agitation and hallucinations. These are being treated with Ativan. Ativan dose has been increased recently. She is minimally verbal. She is needing routine Tylenol for chronic knee pain. She does continue a slow decline overall and is appropriate for hospice care.” The hospice medical director’s written CTI for the fifth benefit period beginning 09/13/2023 through 11/11/2023 was signed and dated 10/03/2023 - twenty days after the beginning of the certification period. There was no verbal certification documented in the clinical record. CTI benefit period 5 dated 9/12 and signed 10/3/23. “Pt is disoriented and forgetful, dizziness when standing, SO with moderated exertion, 1+ scant edema, BLE, A&Ox1 person, pt is disengaged and withdrawn, pt has unsteady gait but refuses to utilize walker, decreased appetite, only 50% or less of small meals, uninterested in meals, pt vitals are stable, increased periods of daytime sleeping for past 3 days, pt agitation hasn’t been as bad, pt is consolable and redirectable, pt sleeps 10+ hours within 24 hour period, pt does not join in conversations, no reports of pain, she continues a slow decline and continues to be appropriate for hospice care.” Benefit Period 2 (2/15/23 - 5/15/23); Benefit Period 3 Face-to-Face 05/02/2023 for 05/16/2023-07/14/2023; Benefit Period 4 Face-to-Face 06/27/2023 for 07/15/2023-09/12/2023; Benefit Period 5 Face-to-Face 09/12/2023 for 09/13/2023-11/11/2023. Clinical Record 12: The patient elected the hospice benefit on 07/20/2023 and was discharged from hospice services on 10/26/2023. The hospice medical director’s written certification of terminal illness (CTI) for the first certification period beginning 07/20/2023 through 10/17/2023 was signed and dated 04/25/2023. There was no verbal certification documented in the clinical record. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 10/18/2023 through 01/15/2024 was not found documented in the clinical record. There was a place holder entry where the CTI for benefit period five that read “not yet started.” Clinical Record 13: The patient elected the hospice benefit on 08/28/2023 and died on hospice services on 02/09/2024. The hospice medical director’s written certification of terminal illness (CTI) for the first certification period beginning 08/28/2023 through 11/25/2023 was signed and dated 09/07/2023 - ten days after the beginning of the certification period. There was no verbal certification documented in the clinical record. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 11/26/2023 through 02/23/2024 was signed and dated 12/17/2023 - twenty-one days after the beginning of the certification period. There was no verbal certification documented in the clinical record. Clinical Record 14: The patient elected the hospice benefit on 07/25/2023 and died on hospice services on 10/24/2023. The hospice medical director’s written certification of terminal illness (CTI) for the first certification period beginning 07/25/2023 through 09/22/2023 was signed and dated 09/07/2023 - forty-four days after the beginning of the certification period. There was no verbal certification documented in the clinical record. The hospice medical director’s written certification of terminal illness (CTI) for the second certification period beginning 09/23/2023 through 11/21/2023 was signed and dated 10/03/2023 - ten days after the beginning of the certification period. There was no verbal certification documented in the clinical record. A joint clinical record review and interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/02/2024 confirmed that the above-mentioned physician certifications were not located in the clinical records and/or were signed more than two days after the beginning of the certification periods. He began training for the Administrator position in September 2023 and assumed the role of Patient Care Coordinator in December 2023. He was not familiar with the practice of obtaining verbal consent from the hospice physician if the certification could not be signed within the two-day regulatory period.”

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed in which there was a live discharge from the hospice agency revealed the agency did not ensure that the receiving facility received a copy of the patient’s discharge summary for continuity of care. The agency policy (Review/Revised 10/12/2018) titled “Discharge from Hospice Program” (Policy No. H: 2-085) included in part that “...When a patient is discharged, transferred, or referred to another organization, relevant information will include reason for transfer or discharge, physical and psychosocial status at the time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up, summary of the care provided and progress toward achieving goals ... a copy of the current plan of care, a copy of the medication profile... the latest physician orders, continuing symptom management needs ... instruction and referrals provided to the patient, existence of any Advance Directives ... Documentation will be filed in the clinical record. Information will be documented on discharge/tranter form, which is to be completed within 72 hours...A copy of the discharge summary will be sent to the attending physician...” Discharge Summary Policy No. H:2-086 All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. :Hospice personnel who provide care will compete a discharge summary at the time the discipline is discontinued, which may include ... the date of discharge, the date th physician and patient informed of discharge, the reason for discharge, including the name of the organization to which the patient is being transferred, if applicable, the status of problems identified at admissions and during the provision of care, the resolution of identified problems, continuing symptom management needs, the overall status of the patient, a summary of care or services provided including treatments, symptoms, and pain management... The discharge summary ... will be completed and submitted within 72 hours of discharge from service. A copy of the discharge summary will be provided to the patient’s attending.” Clinical Record 11: The patient elected the hospice benefit on 11/17/2022 and was discharged for an extended prognosis on 09/29/2023. There was no documentation in the clinical record that the discharge summary or any clinical information was forwarded to the receiving agency for continuity of care. Clinical Record 12: The patient elected the hospice benefit on 07/20/2023 and revoked hospice services on 10/26/2023 to seek aggressive treatment. There was no documentation in the clinical record that the discharge summary or any clinical information was forwarded to the receiving hospital for continuity of care. During a joint record review and interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/02/2024 and 05/03/2024, it was determined that the patient’s clinical records contained no documentation that any of the patient’s clinical information was provided to the hospital or to the patient’s attending physician.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) clinical records reviewed in which there was a live discharge from the hospice agency revealed the agency did not ensure that a discharge summary was documented with the required information. The policy (Review/Revised 10/12/2018) titled, “Discharge Summary” (Policy No. H:2-086) included in part that “... All patients discharged from ...hospice will have a discharge summary completed and filed in the clinical record. Hospice personnel who provide care will compete a discharge summary ...which may include ... the date of discharge, the date the physician and patient were informed of discharge, the reason for discharge, including the name of the organization to which the patient is being transferred, if applicable, the status of problems identified at admissions and during the provision of care, the resolution of identified problems, continuing symptom management needs, the overall status of the patient, a summary of care or services provided including treatments, symptoms, and pain management... The discharge summary ... will be completed and submitted within 72 hours of discharge from service.” Clinical Record 11: The patient elected the hospice benefit on 11/17/2022 and was discharged for extended prognosis on 09/29/2023. There was no discharge summary documented in the clinical record and no evidence of any clinical information forwarded for continuity of care. Clinical Record 12: The patient elected the hospice benefit on 07/20/2023 and revoked hospice services on 10/26/2023 to seek aggressive treatment. No discharge summary was documented in the clinical record, and no evidence of any clinical information was forwarded for continuity of care. During a joint record review and interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/02/2024 and 05/03/2024, it was determined that the patient’s clinical records did not include a discharge summary.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review of contracts, personnel files and interview. The agency did not ensure for that the Pharmacy, Durable Medical Equipment, General Inpatient Care - Hospital, Respite - Nursing Facility, the Physical/Speech/Occupational Therapy, the hospice Medial Director and Associate Medical Director contracts included the requirement for criminal background checks for anyone with access to the agency’s hospice patients or to the hospice patients’ medical records. During the interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/03/2024, he confirmed after his own review of the contracts that the provision requiring criminal backgrounds was missing from the aforementioned contracts. This standard was not met as evidenced by a review of contracts and the personnel files for the two hospice physicians along with an interview with the Administrator that revealed the Pharmacy, Durable Medical Equipment, General Inpatient Care - Hospital, Respite - Nursing Facility, the Physical/Speech/Occupational Therapy, the hospice Medial Director and Associate Medical Director contracts all failed to include the requirement for criminal background checks for anyone with access to the agency’s hospice patients or to the hospice patients’ medical records. During the interview with the Administrator/Patient Care Coordinator (Personnel Record 1) on 05/03/2024, he confirmed after his own review of the contracts that the provision requiring criminal backgrounds was missing from the aforementioned contracts.”