St. Joseph’s Hospice Care

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure that the designated RN established an interdisciplinary plan of care for each patient {HCPC.19. I/L540/ 418.56(a)}; and Failed to ensure that each patient had an individualized written plan of care with planned interventions based on problems identified in the initial and that there was an individualized plan of care for each patient that included measurable outcomes anticipated from implementing and coordinating the plan of care. {HCPC.21. I/L545/ 418.56(c)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record reviews, personnel record reviews and interviews which revealed the agency: Failed to ensure that all core services were provided directly by a hospice employee {HCDT.1.I/L652/418.100(c)(1); and Failed to ensure that an organized bereavement program, including a bereavement plan of care and the type of bereavement services or the frequency of service delivery, was provided {HCDT.22. I/L596/ 418.64(d)(1)(i)}. 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 418.64: Core Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by a document review, and interview which revealed the hospice: Failed to ensure that volunteers were used in day-to-day administrative and/or direct patient care roles {HCDT.21. I/L644/ 418.78(b)}; Failed to ensure that agency had ongoing efforts to recruit and retain volunteers {HSRM.30.I/L645/ 418.78(c)}; and Failed to ensure that hospice volunteers provided 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 for 2024 {HSLG.7.I/L647/ 418.78(e)}. 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 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met, as shown by reviews of documents, personnel records, clinical records, and interviews, which revealed problems with the governing body’s oversight regarding the organization, management, and administration of resources necessary to provide hospice care and services in the following areas: Failed to ensure that the governing body employed safeguards that care and services provided were consistent with the accepted standards of practice. {HCDT.1. I/L652/ 418.100(c)(1)}; Failed to ensure that the skills and competencies of all individuals providing care were assessed {HSRM.14. I/L663/ 418.100(g)(3)}; and Failed to ensure the governing body provided oversight and management of hospice operations to ensure that the provisions of care and services followed individualized plan of care, volunteer program, core services were provided by direct employees, and bereavement services in compliance with the associated regulations {HSLG.2. I/L651/418.100(b)}. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical record review revealed that the agency did not ensure that the initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. The agency policy titled Hospice Policy and Procedure Manual Plan of Care states “Based on the needs identified in the comprehensive assessments (performed no later than 5 days after the election of hospice), the IDG will, in collaboration with the patient’s attending physician, if any, further develop the written plan of care.” CLINICAL RECORD 3: The patient elected the hospice benefit on 12/02/2024. There was no documented evidence that an initial comprehensive spiritual assessment was completed within five days of the election of benefit as of the end of the site visit on 02/06/2025, (66 days). CLINICAL RECORD 7: The patient elected the hospice benefit on 08/01/2024. A review of the clinical record revealed the registered nurse (RN) stated in the RN initial comprehensive assessment “Needs spiritual support? Yes”. There was no documented evidence that an initial comprehensive spiritual assessment was completed within five days of the election of benefit as of the end of the site visit on 02/06/2025, (189 days). CLINICAL RECORD 12: The patient elected the hospice benefit on 01/24/2024. A review of the clinical record revealed the initial spiritual assessment was done on 02/24/2024, (31 days). During an interview with the Administrator/DON on 02/05/2025, she stated that they will ensure that the clinical staff is provided with additional education on the importance of documenting whether spiritual services are requested.”

“It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 14 of 14 (100%) records reviewed revealed the agency did not ensure that the designated RN established an interdisciplinary plan of care for each patient. The agency policy titled Hospice Policy and Procedure Manual Plan of Care stated in part “The RN will coordinate the implementation of the plan of care for each patient” CLINICAL RECORD 1: The patient elected the hospice benefit on 09/10/2023 for Alzheimer’s. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/12/2024 for Alzheimer’s. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/02/2024 for Senile degeneration. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/14/2024 for Alzheimer’s. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/29/2024 for Malignant neoplasm of endometrium. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/22/2024 for Hemiplegia. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/01/2024 for Senile degeneration. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 8: The patient elected the hospice benefit on 01/20/2024 for Malignant neoplasm of vertebral column. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/24/2023 for Alzheimer’s. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 10: The patient elected the hospice benefit on 08/24/2023 for Alzheimer’s. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/30/2024 for Senile degeneration. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/24/2024 for congestive heart failure. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 13: The patient elected the hospice benefit on 02/07/2024 for chronic kidney disease. A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. CLINICAL RECORD 14: The patient elected the hospice benefit on 06/08/2024 for Alzheimer’s A review of the clinical record lacked evidence of the designated registered nurse implementing an individualized plan of care. A review of the clinical record revealed verbal orders were present to support delivery of care, including admission orders, treatment orders, current medications, and vital sign parameters for when to notify the physician. A review of the clinical record revealed there was no documented evidence of a written plan of care as of the end of the site visit ending on 02/06/2025. During an interview with the Administrator/Director of Nurses on 02/06/2025, she stated that she has been unable to figure out how to add care plans to the current electronic health record but will call support. In addition, she stated she is new to hospice but that she did pull the agency policy and will be herself and the staff on the plan of care, as well as calling support regarding there electronic health record.”

“It is required that each patient’s individualized written plan of care: Reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; Includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms; Measurable outcomes anticipated from implementing and coordinating the plan of care; Drugs and treatment necessary to meet the needs of the patient; Medical supplies and appliances necessary to meet the needs of the patient; Includes the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC; The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review, document review, and interview. In 13 of 14 (93%) clinical record review revealed that the agency did not ensure that each patient had an individualized written plan of care with planned interventions based on problems identified in the initial and updated comprehensive assessments that included the measurable outcomes anticipated from implementing and coordinating the plan of care. Document 5: The agency policy titled Hospice Policy and Procedure Manual Plan of Care stated in part “The written plan of care, with a focus on palliative care, will include the following: problems identified, patient and family goals, interventions to manage pain and symptoms, interventions to assist with end-of-life care, placement at the appropriate level of care. Safety measures to protect against abuse, injury, infection, or communicable disease as appropriate. referrals, as needed to other disciplines, eternal resources. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Measurable outcomes anticipated from implementing and coordinating the plan of care. Drugs and treatment necessary to meet the needs of the patient. Medical supplies and appliances necessary to meet the needs of the patient. The interdisciplinary group’s documentation of the patient’s or representative’s ability to learn and understand teaching, level of understanding, involvement, and agreement with the plan of care. Education and training to the patient and/or the caregiver as appropriate to their responsibilities for the care and services identified in the plan of care. Expected outcomes. techniques for providing care. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/10/2023 for Alzheimer’s. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/12/2024 for Alzheimer’s. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/02/2024 for Senile degeneration. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/14/2024 for Alzheimer’s. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/29/2024 for Malignant neoplasm of endometrium. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/22/2024 for Hemiplegia. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/01/2024 for Senile degeneration. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 8: The patient elected the hospice benefit on 01/20/2024 for Malignant neoplasm of vertebral column. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/24/2023 for Alzheimer’s. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/30/2024 for Senile degeneration. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/24/2024 for congestive heart failure. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 13: The patient elected the hospice benefit on 02/07/2024 for Chronic kidney disease. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 14: The patient elected the hospice benefit on 06/08/2024 for Alzheimer’s. A review of the clinical record lacked evidence of a written plan of care. No evidence of goals or interventions to manage pain and/or symptom management, no measurable outcomes anticipated from implementing and coordinating the plan of care. During an interview with the Administrator/Director of Nurses on 02/06/2025, she stated that she has been unable to figure out how to add care plans to the current electronic health record but will call support. She also stated that if medications or treatments are changed during IDG or with changes, an order with directions is written, but the current process does not include adding a goal and/or intervention.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes Education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 9 (22%) personnel records reviewed revealed the agency did not ensure that annual education regarding the infection control program was provided. Document 1: The agency policy titled Hospice Policy and Procedure Manual Infection Control states in part “The hospice will evaluate the effectiveness of the Infection Control Plan, including input from personnel, and its activities annually and whenever risks change...” Personnel Record 4: A review of the Medical Director’s personnel record revealed there was no documented evidence of annual infection control education for 2024. Personnel Record 8: A review of the Volunteer Coordinator’s personnel record revealed there was no documented evidence of annual infection control education for 2024. During an interview with the Administrator/Director of Nurses (DON) on 02/05/2025 she stated that they do have the education material to provide the annual infection education they just need to implement the education schedule.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: The types of bereavement services to be offered; The frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) records reviewed for patient that died revealed that the agency did not ensure that an organized bereavement program, including a bereavement plan of care and the type of bereavement services or the frequency of service delivery, was provided. Document 3: The agency policy titled Bereavement Program stated in part “ALL Bereavement Activities will be documented on Bereavement Plan of Care and Bereavement Progress Noted.” CLINICAL RECORD 8: The hospice benefit period was elected on 01/20/2024, and the date of death was 03/30/2024. A review of the clinical record revealed there was no documented evidence of post-death bereavement services. CLINICAL RECORD 7: The hospice benefit period was elected on 08/01/2024, and the date of death was 10/21/2024. A review of the clinical record revealed there was no documented evidence of post-death bereavement services. During an interview with the Bereavement Coordinator on 02/06/2025, she stated that she has been talking to the bereaved post death, but she did not know where to document the encounter, she also stated that she was unaware of how or where to generate a bereavement plan of care.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview which revealed the agency was not able to produce when requested documentation of records for volunteer use in day-to- day administrative and/or direct patient care roles. During an interview with the Volunteer Coordinator on 02/06/2025 she stated that she is the only one currently functioning as a volunteer, as well as volunteer coordinator. No additional documentation was provided prior to the end of the site visit on 02/06/2025.”

“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 that revealed the agency was not able to produce when requested documentation of any recruitment and retention efforts for the volunteer program. The agency policy titled Hospice Policy and Procedure Manual Volunteer Services stated in part “Performing and documenting efforts to retain volunteers through ongoing recognition, education and support.” During an interview with the Volunteer Coordinator on 02/06/2025 she stated that she is the only one currently functioning as a volunteer, as well as volunteer coordinator. No additional documentation was provided prior to the end of the site visit on 02/06/2025.”

“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 which revealed the agency was not able to produce when requested, any monthly tracking and documentation for hospice volunteer hours. The agency policy titled Hospice Policy and Procedure Manual Volunteer Services stated in part “Performing and documenting efforts to retain volunteers through ongoing recognition, education and support. Monthly tracking and documenting volunteer services, the cost savings achieve through the use of volunteer and the percentage of patient care hours provided by volunteers. To calculate the total volunteer hours provided (with goal of 5%).” During an interview with the Volunteer Coordinator on 02/06/2025 she stated that she is the only one currently functioning as a volunteer, as well as volunteer coordinator. No additional documentation was provided prior to the end of the site visit on 02/06/2025.”

“It is required that the hospice governing body assumes full legal authority for the organization’s overall management and operations, provisions of care and services. This standard was not met as evidence by clinical record reviews and interviews; In 14 of 14 (100%) of clinical records reviewed revealed the governing body did not provide oversight and management of hospice operations to ensure that the provisions of care and services followed individualized plan of care, volunteer program, core services provided by direct employees, and bereavement services. [Clinical Records 1-14}. In 2 of 2 (100%) clinical record reviewed for patients that transferred to another facility revealed that the agency did not ensure a discharge summary was sent to the receiving facility. {[Clinical Records 9 and 13]. In 4 of 4 (100%) clinical records reviewed for patients that revoked their hospice benefit revealed that the agency did not ensure a discharge summary was sent to the patient’s attending physician following a revocation or discharge from hospice. [Clinical Records 9, 10, 12, and 14]. In 13 of 13 (100%) clinical record review revealed that the agency did not ensure that each patient had an individualized written plan of care with planned interventions based on problems identified in the initial and updated comprehensive assessments that included the measurable outcomes anticipated from implementing and coordinating the plan of care. [Clinical Records 1-9, 11-14]. There was no documented evidence that the governing body assumed responsibility and oversight for the management of the operations and the service delivery of care in the fourteen (14) records and documents reviewed.”

“It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Medical social services, and volunteer services. This standard was not met as evidence by personnel record review and interview. In 2 of 8 (25%) personnel records reviewed revealed that the governing body did not ensure that the care and services were consistent with the accepted standards of practice. Personnel Record 7: A review of the LMSW with a hire date of 09/26/2024 revealed the LMSW was a contracted and not a direct employee. Personnel Record 8: A review of the Volunteer Coordinator’s personnel record revealed there was no documented evidence of a volunteer job description or orientation to the role of the volunteer. During an interview with the administrator/director of nurses on 02/05/2025, she stated that the MSW is a contracted employee and submits an invoice that is then paid. During an interview with the Volunteer Coordinator on 02/06/2025 she stated that she is the only one currently functioning as a volunteer, as well as volunteer coordinator.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 4 of 8 (50%) personnel records reviewed revealed that the agency did not ensure that the skills and competencies of all individuals providing care were assessed. Personnel Record 1: The Registered Nurse/Administrator/Director of Nurses was hired on 02/06/2024. A review of the personnel record revealed there was no documented evidence of an initial competency assessment. Personnel Record 2: The Certified Nurse Aide was hired on 02/27/2024. A review of the personnel record revealed there was no documented evidence of an initial competency assessment. Personnel Record 7: The License Medical Social Worker was hired on 09/26/2024. A review of the personnel record revealed there was no documented evidence of an initial competency assessment. Personnel Record 9: The Registered Nurse/Alternate Administrator was hired on 02/08/2024. A review of the personnel record revealed there was no documented evidence of an initial competency assessment. During an interview with the Administrator/Director of Nurses on 02/05/2025 she stated that they have new personnel and will be getting additional education and will complete the competencies as soon as possible.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: The primary terminal condition; Related diagnosis(es), if any; Current subjective and objective medical findings; Current medication and treatment orders; Information about the medical management of any of the patient’s conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure the medical director considered the patient’s subjective and objective medical findings, current medication and treatment orders, and information about medical management when providing the written certification of terminal illness. CLINICAL RECORD 1: The patient’s election of the hospice benefit was dated 09/10/2023 with a diagnosis of Alzheimer’s disease with late onset. There was no documented evidence that the medical director considered the patient’s subjective and objective medical findings, current medication and treatment orders, and information about medical management when providing the written certification of terminal illness (CTI). The CTIs for benefit periods 09/10/2023-12/07/2023, 12/08/2023-03/06/2024, 03/07/2024-05/06/2024, 05/07/2024-07/05/2024 all included the identical physician statement “91-year-old female with late onset Alzheimer’s dementia. Patient is essentially nonverbal confined to her wheelchair and bed requires assistance for all independent activities of daily living significantly debilitated and frail. Patient continues to lose weight and is clinically declining and in all medical probability should disease pursue its natural course would not survive greater than 6 months in my opinion”. CLINICAL RECORD 13: The patient’s election of the hospice benefit was dated 02/07/2024 with a diagnosis of chronic kidney disease, stage 3 unspecified. There was no documented evidence that the medical director considered the patient’s subjective and objective medical findings, current medication and treatment orders, and information about medical management when providing the written certification of terminal illness (CTI). The CTIs for benefit periods 02/07/2024-05/06/2024 and 05/07/2024-08/04/2024 all included the identical physician statement “admitted to hospice for chronic kidney disease, hypertension, and diabetes mellitus type 2 pt has been declining clinically and refuses aggressive medical care. Family and patient has opted for hospice and comfort care. She continues to require assistance with IADL’s at risk for falls and hip fracture. If disease process continues along its natural course in all medical probability survival is less than 6 months”. CLINICAL RECORD 14: The patient’s election of the hospice benefit was dated 06/08/2024 with a diagnosis of for Alzheimer’s Disease. There was no documented evidence that the medical director considered the patient’s subjective and objective medical findings, current medication and treatment orders, and information about medical management when providing the written certification of terminal illness (CTI). The CTIs for benefit periods 06/08/2024-09/05/2024, 09/06/2024-12/04/2024, and 12/05/2024-02/02/2025 all included the identical physician statement “admitted to hospice for chronic kidney disease, hypertension, and diabetes mellitus type 2 pt has been declining clinically and refuses aggressive medical care. Family and patient has opted for hospice and comfort care. She continues to require assistance with IADL’s at risk for falls and hip fracture. If disease process continues along its natural course in all medical probability survival is less than 6 months”. During an interview with the Medical Director on 02/06/2025, he stated that if the patient’s condition did not change, he would not change his narrative; therefore, it would look like copying and pasting. When asked additional questions about the content of his narrative, he stated, “Well, I guess the staff will need to give me a more thorough report.””

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that the recertification was 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. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/10/2023. A clinical record review revealed the Medical Director signed the Certification of Terminal Illness (CTI) for the benefit period 01/02/2025 to 03/02/2025 on 12/06/2024 (27 days before the start of the benefit period). CLINICAL RECORD 12: The patient elected the hospice benefit on 01/24/2024. A clinical record review revealed the Medical Director signed the Certification of Terminal Illness (CTI) for the benefit period for the benefit period 08/21/2025 to 10/19/2024 on 07/24/2024(31 days before the start of the benefit period). During an interview with the Hospice Medical Director on 02/06/2025, he stated that it was the agency’s responsibility to keep up with the dates, not his. During an interview with the Administrator/Director of Nurses on 02/05/2025, she stated that she was aware that the face-to-face interview could not be done prior to 30 days before the start of the new benefit period, but she would be sure to monitor the dates on which the CTI is completed and signed.”

“It is required if the hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: (L682) 1. The hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical record reviewed for patients that transferred to another facility revealed that the agency did not ensure a discharge summary was sent to the receiving facility. CLINICAL RECORD 11: The patient elected hospice services on 05/30/2024 and was transferred to another hospice agency on 11/19/2024. A review of the clinical record revealed no documented evidence that the discharge summary was sent to the receiving facility. CLINICAL RECORD 13: The patient elected hospice services on 02/07/2024 and was transferred to another hospice agency on 05/29/2024. A review of the clinical record revealed no documented evidence that the discharge summary was sent to the receiving facility. During an interview with the administrator/director of nurse on 02/06/2025, she stated that as an agency they will be implementing a new process to fax the discharge summary.”

“t 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; The patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical record reviewed for patients that revoked their hospice benefit revealed that the agency did not ensure a discharge summary was sent to the patient’s attending physician following a revocation or discharge from hospice. The agency policy titled Hospice Policy and Procedure Manual Discharge from Hospice Care stated in part “Provide a copy of the Discharge Summary and, if requested, a copy of the Clinical record to the attending physician if any, and other service providers who will provide care, treatment, or services to the patient.” CLINICAL RECORD 9: The patient elected hospice services on 08/24/2023 and chose to revocate hospice services on 07/03/2024. A review of the clinical record revealed no documented evidence that the discharge summary was sent to the attending physician. CLINICAL RECORD 10: The patient elected to revocate hospice services on 09/15/2024. A review of the clinical record revealed no documented evidence that the discharge summary was sent to the attending physician. CLINICAL RECORD 12: The patient elected hospice services on 01/24/2024 and chose to revocate hospice services on 08/13/2024. A review of the clinical record revealed no documented evidence that the discharge summary was sent to the attending physician. CLINICAL RECORD 14: The patient elected hospice services on 06/08/2024 and chose to revocate hospice services on 12/06/2024. A review of the clinical record revealed no documented evidence that the discharge summary was sent to the attending physician. During an interview with the administrator/director of nurse on 02/06/2025, she stated that as an agency they will be implementing a new process to fax the attending the discharge summary.”