Medcore Preferred Hospice

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records review and interview revealed the agency did not ensure that an initial bereavement assessment was completed. Clinical Record 1: The patient’s election of the hospice benefit was effective 06/04/2024. There was no evidence of a completed initial bereavement assessment as of the clinical record review on 07/02/2024. Clinical Record 4: The patient’s election of benefit was effective 03/05/2024. There was no evidence of a completed initial bereavement assessment as of the clinical record review on 07/02/2024. The DON was interviewed on 07/02/2024 during a joint review of the clinical records and confirmed that the initial bereavement assessments were not completed.”

“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. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met, as evidenced by a review of clinical records, interviews, document review, and interviews, which revealed the hospice failed to ensure that the patient’s record included the initial assessment. [HSIM.3.I/L672]; failed to ensure that the patient’s record included signed copies of the notice of patient rights and the hospice election statement [HSIM.3.I/L673]; failure of the governing body and the administrator to ensure that the patient’s clinical record was safeguarded against loss [HSIM.5.I/L680]; revealed that the governing body and the administrator failed to ensure the patient’s clinical record was retained for the period of time as outlined in the agency policy [HSIM.1.D/L681]; failed to ensure that the discharge summary was forwarded to the patient’s attending physician (HSIM.3.I/L683); and failed to ensure the discharge summary was provided to the receiving facility [HCDT.40.I/L684]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to significantly compromise the care of all patients served by the agency.”

“It is required that the written Patient Bill of Rights includes the right to have a confidential record per state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical records reviewed in which the patient requested a copy of their medical record, the hospice did not ensure that the patient had access to their clinical record upon request. Document 1: Agency policy, IM.50 Medical Record Information Release and Removal, stated in part, “Protected health information is retained by the Hospice for seven years from the last date it is in effect. The Hospice will provide the patient with access to the protected health information in the form and format requested by the individual.” Document 7: The Hospice Patient Binder Bill of Rights, reviewed on 05/20/2024, revealed the patient has the right to request access to your health information, to inspect or copy it. Clinical Record 7: The patient was referred to hospice on 01/19/2024. The clinical record included a face sheet. The consents, election of hospice benefit, and a signed acknowledgment of the patient’s rights and responsibilities were completed on 01/19/2024. The initial nurse assessment was completed by the Assistant Director of Nursing (ADON) on 01/22/2024. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. There was no documented evidence that the clinical record was requested by the patient or provided. The Alternate Administrator was interviewed on 05/20/2024 and stated that the patient (CR 7) had requested her medical record. The Alternate Administrator stated that the consents signed were sent to the patient upon request, but the initial assessment was not. The Alternate Administrator stated that all information is shredded after the initial visit if they don’t admit. “We don’t keep anything. We didn’t have a documented initial assessment to send.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum the initial assessment and clinical notes. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) clinical records reviewed of initial assessments completed and not admitted revealed that the hospice did not ensure that the patient’s record included the initial assessment. Document 1: Agency policy, IM.50 Medical Record Information Release and Removal, stated in part, “Protected health information is retained by the Hospice for seven years from the last date it is in effect.” Document 2: Agency policy, PE.5 Patient Assessments, stated in part, “The initial assessment will be documented in the clinical record.” Clinical Record 4: The patient was referred to hospice on 04/28/2024. The clinical record included a face sheet. During an interview on 5/20/2024, the Alternate Director of Nursing (ADON) stated that she completed the initial assessment for this patient on 04/28/2024. The ADON provided a printout from a secure text message system sent to the medical director that showed notes from the initial assessment completed on 04/28/2024. However, there was no documented evidence in the clinical record that the initial assessment was completed. Clinical Record 6: The patient was referred to hospice on 03/04/2024. The clinical record included a face sheet. During an interview on 5/20/2024, the ADON stated that an RN completed the initial assessment on 03/10/2024 as she had assigned. However, there was no documented evidence that the initial assessment was completed. Clinical Record 7: The patient was referred to hospice on 01/19/2024. The clinical record included a face sheet. During an interview on 5/20/2024, the ADON stated that she completed the initial assessment for this patient on 01/22 /2024. However, there was no documented evidence in the clinical record that the initial assessment completed. During a joint record review and interview on 05/20/2024, the Administrator stated, “We just have the face sheet. If we don’t admit them, we only create a face sheet in the record. When they don’t admit a patient, we shred everything, the consents, the H&P, clinical information. We haven’t even gone in and told the system they didn’t admit. We didn’t realize we needed to. That was our mistake.” The Administrator agreed the hospice policy was not followed. During a joint record review and interview on 05/20/2024, the Alternate Director of Nursing (ADON) stated that the initial assessments for the records identified (CR 4, 6 &7) were completed by a Registered Nurse on the dates identified above. The ADON printed a phone text message the RN sent to the medical director with the initial assessment information for clinical record 4. The ADON agreed the initial assessments were not documented in the clinical record for clinical record 4, 6, and 7, but stated, “We can add this text printout to the record (CR 4) now, the text assessments for the other two (CR 6 &7) are gone, they disappear after about a month.” The ADON stated, “Once they don’t admit, we (RN) bring everything back to the office and everything is shredded. We don’t keep anything. I didn’t know we needed to document it since they didn’t admit.” The ADON confirmed there were no other records, on paper or electronically, for the clinical records identified. “We just have the face sheet in the computer.” The Alternate Administrator was interviewed on 05/20/2024 and agreed that all information is shredded after the initial visit if they don’t admit. “We don’t keep anything.” The Alternate Administrator stated that the text messages are HIPAA compliant, “though they disappear around 3-4 weeks.””

“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 signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) clinical records reviewed in which the patient was not admitted after the completion of an initial assessment, the hospice did not ensure that the patient’s record included signed copies of the notice of patient rights and the hospice election statement. Document 1: Agency policy, IM.50 Medical Record Information Release and Removal, stated in part, “Protected health information is retained by the Hospice for seven years from the last date it is in effect.” Document 5: Agency policy, IM.30 Medical Record Content, “Each medical record will contain the patient or the representative(s) acknowledge receipt of informed consent, hospice election of hospice service, notice of the patient’s rights and responsibilities.” Clinical Record 4: The consents, election of hospice benefit, and a signed acknowledgment of the patient’s rights and responsibilities were completed on 04/28/2024 before the initial nurse assessment. The clinical record included a face sheet. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, and the hospice election statement. Clinical Record 6: The consents, election of hospice benefit, and a signed acknowledgment of the patient’s rights and responsibilities were completed on 03/10/2024 before the initial nurse assessment. The clinical record included a face sheet. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, and the hospice election statement. Clinical Record 7: The consents, election of hospice benefit, and a signed acknowledgment of the patient’s rights and responsibilities were completed on 01/19/2024. The initial nurse assessment was completed on 01/22/2024. The clinical record included a face sheet. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, and the hospice election statement. During a joint record review and interview on 05/20/2024, the Administrator stated, “We just have the face sheet. If we don’t admit them, we only create a face sheet in the record. When they don’t admit, we shred everything, the consents, the H&P, and clinical information. We haven’t even gone in and told the system they didn’t admit. We didn’t realize we needed to. That was our mistake.” The Administrator agreed the hospice policy was not followed. During a joint record review and interview on 05/20/2024, the Alternate Director of Nursing (ADON) stated that the consents, election of hospice benefit, and a signed acknowledgment of the patient’s rights and responsibilities were completed on the dates identified above. The ADON agreed the consents, election of hospice benefit, and a signed acknowledgment of the patient’s rights and responsibilities were not documented in the clinical record for clinical record 4, 6, and 7. The ADON stated, “Once they don’t admit, everything is shredded. We don’t keep anything. I didn’t know we needed to document it since they didn’t admit.” The ADON confirmed there were no other records, on paper or electronically, for the clinical records identified. “We just have the face sheet in the computer.” The ADON agreed the hospice policy was not followed.”

“It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use. The hospice addresses leaving and protecting patient record information in the home; and prevention of physical or electronic altering of the patient record. The hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) clinical records reviewed in which the patient was not admitted after the completion of an initial assessment ,revealed that the governing body and the administrator did not ensure that the patient’s clinical record was safeguarded against loss. Document 1: Agency policy, IM.50 Medical Record Information Release and Removal, stated in part, “Protected health information is retained by the Hospice for seven years from the last date it is in effect.” Document 3: Agency policy, IM.55 Medical Record Information Retention and Destruction, stated in part, “The final disposition and responsibility for the patient’s medical record will rest with the Hospice Administrator and Governing Body.” Clinical Record 4: The patient was referred to hospice on 04/28/2024. The clinical record included a face sheet. The consents, election of hospice benefit, a signed acknowledgment of the patient’s rights and responsibilities, and the initial nurse assessment were completed on 04/28/2024. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. There was no documented evidence that the patient’s clinical record was safeguarded against loss. Clinical Record 6: The patient was referred to hospice on 03/04/2024. The clinical record included a face sheet. The consents, election of hospice benefit, a signed acknowledgment of the patient’s rights and responsibilities, and the initial nurse visit were completed on 03/10/2024. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. There was no documented evidence that the patient’s clinical record was safeguarded against loss. Clinical Record 7: The patient was referred to hospice on 01/19/2024. The clinical record included a face sheet. The consents, election of hospice benefit, and a signed acknowledgment of the patient’s rights and responsibilities were completed on 01/19/2024. The initial nurse assessment was completed on 01/22/2024. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. There was no documented evidence that the patient’s clinical record was safeguarded against loss. During a joint record review and interview on 05/20/2024, the Administrator stated, “We don’t keep any records when they don’t admit, they are shredded. If we don’t admit them, we only create a face sheet in the record. When they don’t admit, we shred everything, the consents, the H&P, clinical information. We haven’t even gone in and told the system they didn’t admit. We didn’t realize we needed to. That was our mistake.” The Administrator agreed there was no documented evidence that the clinical record was safeguarded against loss. The Administrator agreed the hospice policy was not followed. During a joint record review and interview on 05/20/2024, the Alternate Director of Nursing (ADON) stated that the consents, election of hospice benefit, a signed acknowledgment of the patient’s rights and responsibilities, and the initial assessments were completed on the dates identified above. The ADON agreed there was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. The ADON stated, “Once they don’t admit, we (RNs) bring everything back to the office and everything is shredded. We don’t keep anything. I didn’t know we needed to keep it.” The ADON confirmed there were no other records, on paper or electronically, for the clinical records identified. The ADON agreed there was no documented evidence that the clinical record was safeguarded against loss. The ADON agreed the hospice policy was not followed. The alternate administrator was interviewed on 05/20/2024 and agreed that all information is shredded after the initial visit if they don’t admit. “We don’t keep anything.””

“It is required that information management policies and procedures (P&P) address how the hospice documents, collects, retrieves, protects, shares, and retains information in accordance with state and federal law and regulation. Patient clinical records are retained for six (6) years after the death or discharge of the patient unless state law stipulates a longer time period. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) clinical records reviewed in which the patient was not admitted after the completion of an initial assessment, the governing body and the administrator did not ensure that the patient’s clinical record was retained for the period of time as outlined in the agency policy. Document 1: Agency policy, IM.50 Medical Record Information Release and Removal, stated in part, “Protected health information is retained by the Hospice for seven years from the last date it is in effect.” Document 3: Agency policy, IM.55 Medical Record Information Retention and Destruction, stated in part, “The final disposition and responsibility for the patient’s medical record will rest with the Hospice Administrator and Governing Body.” Clinical Record 4: The patient was referred to hospice on 04/28/2024. The clinical record included a face sheet. The consents, election of hospice benefit, a signed acknowledgment of the patient’s rights and responsibilities, and the initial nurse assessment were completed on 04/28/2024. During an interview on 5/20/2024, the Alternate Director of Nursing (ADON) stated that she completed the initial assessment for this patient on 04/28/2024. The ADON provided a printout from a secure text message system sent to the medical director that showed notes from the initial assessment completed on 04/28/2024. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. There was no documented evidence that the clinical records were retained by the Hospice according to agency policy. Clinical Record 6: The patient was referred to hospice on 03/04/2024. The clinical record included a face sheet. The consents, election of hospice benefit, a signed acknowledgment of the patient’s rights and responsibilities, and the initial nurse visit were completed on 03/10/2024. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment completed on 03/10/2024. During an interview on 5/20/2024, the ADON stated that an RN completed the initial assessment on 03/10/2024 as she had assigned. The agency was unable to provide any of the aforementioned documentation in the clinical record because it had been destroyed. There was no evidence that the clinical records were retained by the Hospice according to agency policy. Clinical Record 7: The patient was referred to hospice on 01/19/2024. During an interview on 5/20/2024, the ADON stated that she completed the initial assessment for this patient on 01/22/2024, and the preadmission documentation completed on 01/19/2024. The clinical record included a face sheet. The consents, election of hospice benefit, and a signed acknowledgment of the patient’s rights and responsibilities were completed on 01/19/2024. The initial nurse assessment was completed on 01/22/2024. There was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. The agency was unable to provide any of the aforementioned documentation in the clinical record because it had been destroyed. There was no documented evidence that the clinical records were retained by the Hospice according to agency policy. During a joint record review and interview on 05/20/2024, the Administrator stated, “We don’t keep any records when they don’t admit, they are shredded. If we don’t admit them, we only create a face sheet in the record. When they don’t admit, we shred everything, the consents, the H&P, clinical information. We haven’t even gone in and told the system they didn’t admit. We didn’t realize we needed to. That was our mistake.” The Administrator agreed the hospice policy was not followed. During a joint record review and interview on 05/20/2024, the Alternate Director of Nursing (ADON) stated that the consents, election of hospice benefit, a signed acknowledgment of the patient’s rights and responsibilities, and the initial assessments were completed on the dates identified above. The ADON agreed there was no documented evidence that the patient’s record included signed copies of the notice of patient rights, consents, hospice election statement, and the initial assessment. The ADON stated, “Once they don’t admit, we (RNs) bring everything back to the office and everything is shredded. We don’t keep anything. I didn’t know we needed to keep it.” The ADON confirmed there were no other records, on paper or electronically, for the clinical records identified. The ADON agreed the hospice policy was not followed. The alternate administrator was interviewed on 05/20/2024 and stated that all information is shredded after the initial visit if they aren’t admitted. “ We don’t keep anything, and didn’t have a documented initial assessment to send.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 3 (33%) clinical records reviewed in which the patient was a live discharge, the hospice did not ensure that the discharge summary was forwarded to the patient’s attending physician. Document 6: Agency policy, PE.20 Patient Discharge, stated in part, “The Hospice will forward copies of the following to the patient’s Attending Physician upon discharge from the Hospice’s Services: hospice discharge summary.” Clinical Record 3: The patient elected hospice care on 01/31/2024. A discharge summary was initiated but incomplete. The discharge summary revealed that the patient was discharged-no longer terminally ill on 04/29/2024. There was no documented evidence that the discharge summary was completed or sent to the patient’s attending physician. During a joint record review and interview on 05/20/2024, the alternate director of nursing agreed there was no documented evidence that the discharge summary was completed or sent to the patient’s attending physician. The alternate administrator was interviewed on 05/20/2024 and agreed there was no documented evidence that the discharge summary was sent 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 at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed in which the patient was a live discharge, the hospice did not ensure that the discharge summary provided to the receiving facility included the patient’s current plan of care and latest physician orders. Clinical Record 1: The patient elected hospice care on 09/28/2023. A discharge summary revealed that the patient was discharged no longer terminally ill on 02/11/2024. There was no documented evidence that the discharge summary provided to the receiving facility included the patient’s current plan of care and latest physician orders. During a joint record review and interview on 05/20/2024, the alternate director of nursing agreed there was no documented evidence that the discharge summary sent to the receiving facility included the patient’s current plan of care and latest physician orders. The alternate administrator was interviewed on 05/20/2024 and agreed there was no documented evidence that the discharge summary sent to the receiving facility included the patient’s current plan of care and latest physician orders.”

“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 medication review process includes the identification of the following the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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 observation and interview. In 2 of 14 (14%) home visit observations, the agency did not ensure a medication review and reconciliation was completed as part of the updated comprehensive assessment. Home Visit 1: The medication profile dated 10/31/2022 to 12/07/2023 included orders for Diclofenac 1% topical gel apply thin layer on affected skin for pain as needed, Trazadone 50mg tablet take one tablet by mouth every night for insomnia, Acetaminophen 500mg tablet take one tablet every 6 hours as needed for pain, and Quetiapine 25mg tablet take one tablet by mouth nightly. During the home visit observation with the Registered Nurse (RN), the medication profile in the patient’s home folder included documentation that Trazadone, Acetaminophen, and Quetiapine were discontinued on 07/20/2023. The Registered Nurse confirmed that the medications were discontinued on 07/20/2023. Diclofenac 1% topical gel was not included on the medication profile in the home. The RN verified that Diclofenac 1% gel was an active medication. Home Visit 2: During the home visit observation with the hospice aide, review of the patient’s home medications included a bottle for Topiramate 200mg tablet take, one tablet twice daily for seizures, last distributed on 11/22/2023. The medication profile dated 06/23/2023 to 12/07/2023 did not include Topiramate and the medication was not included in the review and reconciliation of the patient’s medications. The Interim Alternate Director of Nursing confirmed in a joint record review and interview on 12/07/2023 that there was no documented evidence the medications was reconciled at the time of each comprehensive assessment and updated to the drug profile.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure staff performed hand hygiene according to agency policy. Agency policy IC.15 Hand Hygiene, dated 12/15/2022, stated in part, “Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: prior to initial entry into the supply bag, immediately before touching a patient, after touching a patient or the patient’s immediate environment, and after removing gloves.” Home Visit 1: During the home visit observation with the Registered Nurse (RN), the RN was observed to donn gloves and touched the patient’s bed controls. Then, without removing the gloves or washing hands, the RN entered the visit bag and removed the blood pressure cuff, a thermometer, and a pulse oximeter, each separately. The RN was observed to enter the visit bag without removing gloves and washing hands prior to entering the clean bag. Home Visit 2: During the home visit observation with the hospice aide, the aide was observed removing gloves and putting on a clean pair without washing the hands after removal of soiled gloves. The Interim Alternate Director of Nursing stated during an interview on 12/07/2023 that the staff did not follow the agency’s hand hygiene policy.”

“It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure the hospice aide provided services included in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 02/20/2020 with a terminal diagnosis of degenerative disease of the nervous system. The hospice aide plan of care assigned the aide the task of feeding assistance. The hospice aide notes dated 11/24/2023, 11/27/2023, 11/29/2023, 12/01/2023, and 12/04/2023 contained no documented evidence that the aide provided feeding assistance as assigned on the aide plan of care. Clinical Record 7: The patient elected the hospice benefit on 10/31/2022 with a terminal diagnosis in Alzheimer’s disease. The hospice aide documented on the aide visit note dated 11/02/2022 that hair care: comb/brush and companionship was provided to the patient. The 11/04/2022 and 11/07/2022 aide visit notes included documentation that the aide provided hair care: comb/brush. The hospice aide visits dated 11/22/2023, 11/22/2023, 11/27/2023, and 11/29/2023 included documentation that the aide provided hair care: comb/brush. The hospice aide plan of care dated 11/01/2022 did not assign the aide the tasks of hair care: comb/brush and provide companionship. Clinical Record 8: The patient elected the hospice benefit on 06/23/2023 with a terminal diagnosis of Alzheimer’s disease. The hospice aide plan of care dated 06/23/2023 assigned the aide the task of feeding assistance. The hospice aide notes dated 06/26/2023, 06/28/2023, and 07/07/2023 contained no documented evidence that the aide provided feeding assistance as assigned on the aide plan of care. The hospice aide notes dated 06/26/2023, 06/28/2023, and 07/07/2023 included documentation that the aide provided toilet: urinal, hair care: shampoo, and shave: face. The hospice aide plan of care dated 06/23/2023 did not assign the aide the tasks of toilet: urinal, hair care: shampoo, and shave: face. The Interim Alternate Director of Nursing confirmed during a joint record review and interview on 12/07/2023 that the hospice aide did not provide services as assigned on the plan of care.”

“It is required the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the drugs and biologicals related to the palliation and management of the terminal illness and related conditions were provided to a patient while under the care of a hospice. Clinical Record 1: The patient elected the hospice benefit on 11/02/2023 with a terminal diagnosis of cytomegaloviral pneumonitis. The medication profile dated 11/02/2023 to 12/07/2023 included orders for, Alprazolam (antianxiety medication) 0.5mg tablet take one tablet by mouth at bedtime, discontinue if patient consistently refuses, not related, Senna (laxative medication) 8.6mg tablet take one tablet daily for constipation, not related, and Gas relief (simethicone) 125mg tablet take, not related. The agency did not ensure medications related to the terminal diagnosis and related conditions were covered under the care of the hospice. Clinical Record 10: The patient elected the hospice benefit on 04/05/2023 with a terminal diagnosis of Parkinson’s disease. The medication profile dated 04/05/2023 to 12/08/2023 included an update on 10/08/2023 that ordered Fleets enema 19 gram-7 gram/118mL insert one daily rectally as needed for constipation, not related, and Lactulose 10 gram/15 mL (15mL) oral solution take 30ML PO twice daily as needed for constipation, not related. The agency did not ensure medications related to the terminal diagnosis and related conditions were covered under the care of the hospice. The Interim Alternate Director of Nursing confirmed during a joint record review and interview on 12/07/2023 that the hospice should have covered the medications listed.”

“It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the clinical record included the physician orders. Home Visit 2/Clinical Record 8: During the home visit observation, review of the patient’s home medications included a bottle for Topiramate 200mg tablet take, one tablet twice daily for seizures, last distributed on 11/22/2023. The patient confirmed it is a medication he/she is currently taking. The medication profile dated 06/23/2023 to 12/07/2023 did not include Topiramate and the clinical record did not include an order for the medication. The Interim Alternate Director of Nursing confirmed in a joint record review and interview on 12/07/2023 that a physician order for the medication was not included in the clinical record.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with live discharge, the agency did not ensure the hospice discharge summary was forwarded to the patient’s attending physician. Clinical Record 12: The patient elected the hospice benefit on 10/29/2022 with a terminal diagnosis of chronic obstructive pulmonary disease. The patient was discharged on 04/06/2023 for no longer terminally ill. There was no documented evidence in the clinical record that the agency forwarded a copy of the discharge summary to the patient’s attending physician. During a joint record review and interview on 12/08/2023, the Interim Alternate Director of Nursing confirmed that the record did not include documentation that a discharge summary was forwarded to the patient’s attending physician.”