Corazon Hospice LLC

“It is required that the hospice must conduct and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL FINDING 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 Interdisciplinary Group completed the patient’s initial comprehensive assessments within five calendar days after admission {HCPC.9. I/L523; Failed to ensure that there was a comprehensive pain assessment documented {HCPC.12. I/L524}; Failed to ensure that the patient’s comprehensive assessment included the components of the objective and subjective symptoms or complaints or the situation and status of the patient leading to hospice admission {HCPC.11. I/L525}; Failed to ensure that every patient’s comprehensive assessment included components of the patient’s functional and cognitive status as well as their ability to participate in their care {HCPC.11. I/L528}; Failed to ensure that the patient’s comprehensive assessment included a complete assessment of the patient’s symptoms {HCPC 11.I/L529}; and Failed to ensure that an initial bereavement risk assessment was completed and documented within the five-day requirement to be included in the comprehensive assessment (HCPC.13. I/L531}. 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 418.54: Initial and comprehensive assessment of the patient. 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 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 hospice nurse provide coordination of care and ensure continuous assessment of each patient’s and family’s needs {HCPC.19. I/L540}; Failed to ensure that each patient’s individualized written Plan of Care included identified problems and planned interventions based upon assessment data from the comprehensive and updated comprehensive assessments (HCPC.21. I/L545}; and Failed to ensure that he patient’s revised plan of care included updates from each Interdisciplinary Group member or progress toward goals documented {HCPC.22. I/L553}. 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 the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensue that the Interdisciplinary Group completed the patient’s initial comprehensive assessments within five calendar days after admission. Clinical Record 3: The patient elected the hospice benefit on 02/20/2024. The Chaplain’s Initial Assessment was not documented until seven days after the patient’s admission on 02/27/2024. The visit note contained no explanation for the delay of the initial visit. No Chaplain note was included in the Interdisciplinary Group Meeting documented 02/22/2024, and no missed visit or communication note was entered. The Registered Nurse (RN) Admission visit documented on 02/20/2024 included no documentation of the patient’s psychological Status, neurological status, sleep/rest, spiritual/religion, integumentary status, respiratory system, cardiovascular system, digestive system, genitourinary system, nutrition/fluid intake screening, fall assessment, or narrative. There was no date or time in or out of the visit. The nurse’s name was included at the bottom of the note. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024. The Chaplain’s Initial Assessment was not documented until seven days after the patient’s admission on 02/27/2024. The visit note contained no explanation for the delay of the initial visit. No Chaplain note was included in the Interdisciplinary Group Meeting documented 02/22/2024, and no missed visit or communication note was entered. The RN Admission visit documented on 02/20/2024 included no documentation of vital signs, no weight and/or mid-arm circumference measurement, no terminal diagnosis, no pain assessment, no ADLs, KPS, FAST, no supportive assistance, psychological status, neurological status, sleep/rest, spiritual/religion, integumentary status, respiratory system, cardiovascular system, digestive system, genitourinary system, nutrition/fluid intake screening, fall assessment, or narrative. The note was blank and included only the date of the visit and the beginning and ending time of the visit. Clinical Record 12: The patient elected the hospice benefit on 03/22/2023. The Initial Social Work assessment was not completed until 04/21/2023. There was no information within the assessment, a communication note, the Interdisciplinary Team Meetings, or a missed visit to explain the delay in the Social Worker’s initial visit. The RN’s Admission Visit on 03/22/2023 did not include any assessment of the patient’s financial resources, the caregiver’s ability to function effectively, the presence or absence of adequate coping mechanisms, or family dynamics, or communication patterns. During an interview with the Director of Nursing on 03/08/2024, she confirmed that she performed the admission visits for the patients in Clinical Record 3 and 4 but had not completed the documentation. The only rationale provided was that she had not been feeling well. Also, during interviews with the Administrator and the Office Coordinator on 03/08/2024 about all three clinical records with late initial comprehensive assessments were confirmed. The late Social Work Assessment in April 2023 occurred prior to the Office Coordinator, or the current Director of Nursing were working at the hospice. No documentation was provided or completed by the end of the site visit.”

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes history of pain and its treatment, both pharmacological and non-pharmacological, use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, characteristics of the pain, including: Location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping), and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that there was a comprehensive pain assessment documented. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024. The RN Admission note dated 02/20/2024 included a blank comprehensive pain assessment and no documentation that any pain was assessed. No nurse visit was documented since the admission visit as of 03/8/2024. The Social Worker documented an Initial Assessment on 02/23/24 and included in part that the patient’s “ ...mood is calm with flat affect...Caregiver reports pt mostly smiles and nods ...mostly stared and smiled ...” The Initial Chaplain visit documented on 02/27/24 noted in part that “...Pt was responsive and comfortable but disoriented ...” It was confirmed during an interview with the Director of Nursing on 03/08/2024 that the documentation for the admission for Clinical Record 4 was incomplete and did not include a pain assessment. Further, in joint record review with the Administrator and the Office Coordinator on 03/07/2024 and 03/08/2024, it was confirmed that the nurse’s admission documentation was incomplete and there were no other nurse visits documented as of 03/08/2024 for Clinical Record 4.”

“It is required that the comprehensive assessment includes consideration of the nature and condition causing admission, including the presence or lack of objective data and subjective complaints or any co-morbid psychiatric diagnosis or history. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the patient’s comprehensive assessment included the components of the objective and subjective symptoms or complaints or the situation and status of the patient leading to hospice admission. The agency policy “Assessments” dated 01/312015 read in part that “The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care... The hospice interdisciplinary group ...will complete the comprehensive assessment no later than 5 calendar days after the election of hospice care .. The hospice policy “Coordination of Services” dated 01/31/2015 read in part that) “...The hospice registered nurse, or designee, will coordinate the assessment of each patient’s and family’s needs and implementation of the patient’s plan of care ... Clinical Record 4: The Registered Nurse (RN) Admission assessment dated 02/20/2024 was incomplete as of 03/08/2024; had no assessment of the reason for the patient’s hospice admission and no assessment data for the patient’s pain, psychological status, neurological status, sleep/rest, integumentary status, respiratory system, cardiovascular system, digestive system, genitourinary system, and nutrition/fluid intake screening. No diagnosis information nor any objective or subjective complaints were documented. During an interview with the Director of Nursing/RN on 03/08/2024, she confirmed that she performed the admission visit on 02/20/2024 but had not completed the documentation. Her only rationale was that she had been sick but was working during at least the last two days of the site visit.”

“It is required that the comprehensive assessment includes consideration of functional status and cognitive status, including the patient’s ability to understand and participate in her or his own care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that every patient’s comprehensive assessment included components of the patient’s functional and cognitive status as well as their ability to participate in their care. The agency policy “Assessments” dated 01/312015 read in part that “The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care... The hospice interdisciplinary group ...will complete the comprehensive assessment no later than 5 calendar days after the election of hospice care ... The hospice policy “Coordination of Services” dated 01/31/2015 read in part that) “...The hospice registered nurse, or designee, will coordinate the assessment of each patient’s and family’s needs and implementation of the patient’s plan of care ... Clinical Record 4: The Registered Nurse (RN) Admission assessment dated 02/20/2024 was incomplete as of 03/08/2024 and did not include assessment of the patient’s functional, cognitive status or ability to understand or participate in their care. During an interview with the Director of Nursing/RN on 03/08/2024, she confirmed that she performed the admission visit on 02/20/2024 but had not completed the documentation. Her only rationale was that she had been sick but was working during at least the last two days of the site visit.”

“It is required that the comprehensive assessment includes symptoms and symptom severity, including dyspnea, nausea, vomiting, constipation, restlessness, anxiety, emotional distress, sleep disorders, skin integrity, and confusion. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure that the patient’s comprehensive assessment included a complete assessment of the patient’s symptoms. The agency policy “Assessments” dated 01/312015 read in part that “The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care... The hospice interdisciplinary group ...will complete the comprehensive assessment no later than 5 calendar days after the election of hospice care. The hospice policy “Coordination of Services” dated 01/31/2015 read in part that “...The hospice registered nurse, or designee, will coordinate the assessment of each patient’s and family’s needs and implementation of the patient’s plan of care ... Clinical Record 3: The Registered Nurse (RN) Admission assessment dated 02/20/2024 did not include assessment data for the patient’s psychological status, neurological status, sleep/rest, integumentary status, respiratory system, cardiovascular system, digestive system, genitourinary system, and nutrition/fluid intake screening. Psychological Status, Neurological Status, sleep/rest, spiritual/religion, Integumentary Status, Respiratory System, Cardiovascular system, digestive system, GU system, Nutrition/fluid intake screening, fall assessment, narrative was blank; no date, no time in/out. Clinical Record 4: The RN Admission assessment dated 02/20/2024 did not include data for the patient’s pain, psychological status, neurological status, sleep/rest, integumentary status, respiratory system, cardiovascular system, digestive system, genitourinary system, and nutrition/fluid intake screening; no vitals, no weight, no terminal dx, no pain assess ,no ADLs, KPS, FAST, No Supportive assistance, Psychological Status, Neurological Status, sleep/rest, spiritual/religion, Integumentary Status, Respiratory System, Cardiovascular system, digestive system, GU system, Nutrition/fluid intake screening, fall assessment, narrative were blank. The document was not signed, no date & time in/out only. During an interview with the Director of Nursing/RN on 03/08/2024, she confirmed that she performed the admission visit on 02/20/2024 but had not completed the documentation. Her only rationale was that she had been sick but was working during at least the last two days of the site visit.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed the agency did not ensure that an initial bereavement risk assessment was completed and documented within the five-day requirement to be included in the comprehensive assessment. The hospice policy “Assessments” dated 01/31/2015 included in part that “...The hospice interdisciplinary group ... will complete the comprehensive assessment non later than 5 calendar days after the election of hospice care ... The comprehensive assessment will include ... 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 will be incorporated into the plan of care and considered in the bereavement plan of care...” The hospice policy “Bereavement Counseling Services” dated 01/31/2025 read in part that “...Upon admission Medical Social Worker (MSW) will complete, no later than 5 days after the election of hospice care an initial bereavement risk assessment on the primary caregiver and each other bereaved identified. If MSW services are declined, Spiritual Counseling Coordinator (SCC) will perform. If MSW and SCC services are declined, Registered Nurse (RN) will perform. Clinical Record 2: The patient elected the hospice benefit on 05/20/2022. The Initial Bereavement Assessment was not documented until 06/11/2022. Neither the Registered Nurse (RN) visit note dated 05/20/2022 nor the Social Work visit documented 05/23/2022 included a Bereavement Risk Assessment. A missed visit documented by the Chaplain on 05/22/2022 was postponed until 06/11/2022. The Interdisciplinary Group Meeting documented 06/01/2022 identified no Bereavement Risk Assessment. The initial Comprehensive Assessment, therefore, did not include a Bereavement Risk Assessment completed within the five-day requirement. Clinical Record 3: The patient elected the hospice benefit on 02/20/2024. As of 03/07/2024, there was no Initial Bereavement Risk Assessment documented. The psychosocial section of the Registered Nurse (RN) visit note dated 02/22/2024 was blank and contained no bereavement risk assessment. The Social Worker performed the first visit on 02/23/2024 but included no bereavement risk assessment. The Chaplain’s visit documented on 02/27/2024 did not include a bereavement risk assessment. The Interdisciplinary Group Meeting documented 02/22/2024 contained no admission bereavement risk assessment. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024. As of 03/07/2024, there was no Initial Bereavement Risk Assessment documented. The psychosocial section of the Registered Nurse (RN) visit note dated 02/22/2024 was blank and contained no bereavement risk assessment. The Social Worker performed the first visit on 02/23/2024 but included no bereavement risk assessment. The Chaplain’s visit documented on 02/27/2024 did not include a bereavement risk assessment. The Interdisciplinary Group Meeting documented 02/22/2024 contained no admission bereavement risk assessment. Clinical Record 9: The patient elected the hospice benefit on 01/20/2024. There was no initial bereavement risk assessment documented. Clinical Record 13: The patient elected the hospice benefit on 02/23/2023. There was no initial bereavement risk assessment documented, During an interview with the Administrator and the Office Coordinator on 03/08/2024 It was confirmed that no initial bereavement risk assessment was completed within the initial five days after the patient’s admission for Clinical Records 2, 3, 4, 9, and 13 and no documentation was produced prior to the end of the site visit.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed revealed that the hospice nurse did provide documented continuous assessment of patient/family needs or ensure the implementation of the interdisciplinary plan of care. The agency policy “Clinical Record” dated 01/31/2015 read in part that “The hospice will establish a record for each patient ...Document all hospice services provided to a patient’s family in the clinical record, whether directly or by contract which must be written the day service is rendered and incorporated into the client record within 14 working days...” The hospice policy “Nursing Services” dated 01/31/2015 include in part the “...The plan of care will be established before providing care and services and the services will be consistent with the plan of care ... The nurse will ...actively participate in the coordination of all aspects of the patient’s hospice care including ... participating/performing ...Development of the Plan of Care on admission with IDG input. The plan of care will be established before providing care and services ... Complete the Comprehensive Plan of Care, including frequencies if services accepted, as related to concerns/needs documented in the Comprehensive Nursing Assessment... implement, evaluate, and update the Plan of Care, which may include ... determining the scope and frequency of services needed based on acuity and patient/family needs... preparing clinical and progress notes that demonstrate progress toward established goals. The agency policy “Interdisciplinary Group” dated 01/31/2015 included in part that “The IDG will include ... the Medical Director, Registered Nurse, Medical Social Worker, Spiritual Care Counselor ... The IDG members will meet...at a minimum of every 15 days to review and update the patient’s written plan of care... The meeting will include ...reports on all care, treatment and services provided since the previous meeting ... included but not limited to problem(s), goal, interventions, outcome/progress toward goals .... the discussion and updates will be documented on the plan of care ...” The hospice policy “Assessments” dated 01/31/2015 included in part that “...The hospice will ensure the update of the comprehensive assessment will be accomplished by the hospice interdisciplinary group ... include information on the patient’s progress toward desired outcomes, as well as reassessment of the patient’s response to care...” The agency policy “Plan of Care” dated 1/31/2015 included in part that “...The written plan of care ... will include problems identified ... interventions to assess with end-of-life care, safety measures to protect against... injury, infection, or communicable disease ... The RN will coordinate the implementation of the plan of care for each patient and is also responsible for ensuring ... ongoing evaluation and assessment of the provision of hospice care for the patient and family, recommending to the IDG modifications to the POC based on response to hospice services ...” Clinical Record 1: The patient elected the hospice benefit on 04/19/2022 with the diagnosis of Alzheimer’s. A Plan of Care Order dated 01/11/2024 (effective 01/09/2024 to 03/08/2024) included a skilled nurse visit frequency of weekly visits. The last documented nurse visit was on 02/14/2024. As of 03/07/2024, sixteen calendar days had passed without another nurse visit documented. Clinical Record 2: The patient elected the hospice benefit on 05/22/2022 with the diagnosis of Alzheimer’s. A Plan of Care Order dated 01/11/2024 (effective 01/10/2024 to 03/09/2024) included a skilled nurse visit frequency of weekly visits. The last documented nurse visit was on 02/12/2024. As of 03/07/2024, eighteen calendar days had passed without another nurse visit documented. A Plan of Care Order dated 12/28/2024 (effective 11/11/2023 to 01/09/2024) and a Plan of Care Order dated 01/11/2024 (01/10/2024 - 03/09/2024) included orders for the Social Worker to visit the patient weekly and the Chaplain to visit the patient twice a week. During January one visit per month each were made by the Social Worker on 01/05/2024 and the Chaplain on 01/06/2024. Again, in February one visit per month was made by the Social Worker on 02/02/2024 and the Chaplain on 02/20/2024. These visits did not make the ordered frequency of weekly. Clinical Record 3: The patient elected the hospice benefit on 02/20/2024 with the diagnosis of Alzheimer’s. As of 03/07/2024, there was only the Initial Admission RN visit documented with no psychosocial, neurological, sleep, skin, respiratory, cardiovascular, digestive/nutrition, genitourinary, or fall assessment documented. The Interdisciplinary Group Meeting (IDG) documented on 02/22/2024 included no frequency orders for the IDG, no coordination of care with the patient/patient representative was documented, and no team notes or updates were included. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024 with the diagnosis of Alzheimer’s. As of 03/07/2024, only the Initial Admission RN visit was documented with no psychosocial, neurological, sleep, skin, respiratory, cardiovascular, digestive/nutrition, genitourinary, or fall risk assessment. The Interdisciplinary Group Meeting (IDG) documented on 02/22/2024 included no frequency orders for the IDG, no coordination of care with the patient/patient representative was documented and no team notes or updates were included. Clinical Record 6: The patient elected the hospice benefit on 04/17/2020. A Plan of Care Order dated 11/29/2023 (effective 10/29/2023 to 12/27/2023), a Plan of Care order dated 12/27/2023 (effective 12/28/2023 to 02/25/2024), and a Plan of Care Order dated 02/22/2024 (effective 02/26/2024 to 04/25/2024) orders for the Chaplain to visit the patient twice a month. The Chaplain documented visits 11/07/2023, 12/20/2023, 01/11/2024, and 02/08/2024. The Chaplain performed visits once a month with no documentation as to why the second visit each month was not performed. Clinical Record 7: The patient elected the hospice benefit on 12/09/2020. A Plan of Care Order dated 11/29/2023 (effective 11/24/2023 to 01/22/2024), a Plan of Care Orderdated01/25/2024 (effective 01/23/2024 to 03/22/2024) included frequency orders for the nurse to visit twice a week. There were sixteen days between RN visits from 12/05/2023 to 12/21/2023. There were fifteen days between the RN visits from 12/21/2023 to 01/05/2023. There were seventeen days between RN visits from 01/16/2024 to 02/02/2024. There were thirty-five days since the last RN documented visit on 02/02/2024 as of 03/08/2024. Clinical Record 14: The patient elected the hospice benefit on 10/18/2019 until the patient passed on service on 09/27/2023. A Plan of Care Order documented 08/09/2023 (effective 07/29/2023 to 09/26/2023) included a visit frequency of once a month for Chaplain visits. There were no Chaplain visits documented for August or September 2023. No missed visits were documented, and no communication notes about visits were made. During an interview with the Administrator and the Office Coordinator on 03/08/2024, it was confirmed that there was no visit documentation except in the Electronic Medical Record and these nursing visits had not been documented. The Administrator noted that the problems with late nursing visit documentation occurred with the turnover of the Director of Nursing role. Further there was discussion that the RN, as the case manager and member of the IDG, is responsible for updating the patient’s plan of care.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure that each patient’s individualized written Plan of Care included identified problems and planned interventions based upon assessment data from the comprehensive and updated comprehensive assessments. The agency policy “Plan of Care” dated 1/31/2015 included in part that “...The written plan of care ... will include problems identified ... interventions to assess with end-of-life measures to protect against... injury, infection, or communicable disease ... The RN will coordinate the implementation of the plan of care for each patient and is also responsible for ensuring ... ongoing evaluation and assessment of the provision of hospice care for the patient and family, recommending to the IDG modifications to the POC based on response to hospice services ...” Clinical Record 3: The patient elected the hospice benefit on 02/20/2024. The only identified problem with related interventions and goals documented for the patient as of 03/07/2024 was the Chaplain’s identified problem of lack of spiritual support. During the home visit observation with the registered nurse (RN) (Personnel Record 2) on 03/07/2024, the caregiver brought the patient’s medications out for the RN to review. These medications included Gabapentin 100mg by mouth three times a day, Levothyroxine 50mcg by mouth daily, and Venlafaxine 150mg by mouth daily. There were no identified problems related to depression or pain. Clinical Record 4: The patient elected the hospice benefit on 02/20/2024. The only identified problem with related interventions and goals documented for the patient as of 03/07/2024 was the Chaplain’s identified problem of lack of spiritual support. During the home visit observation with the RN (Personnel Record 2) on 03/07/2024, the caregiver brought the patient’s medications out for the RN to review. These medications included Fluoxetine 10mg by mouth daily, Metoprolol Succinate 25mg by mouth daily, Eliquis 2.5mg by mouth daily, Amiodarone 200mg by mouth daily, and a bottle of Olanzapine 10mg by mouth at bedtime. There were no identified problems related to depression, agitation/anxiety, or potential for injury/bleeding related to falls secondary to the patient’s Alzheimer’s, poor safety awareness, and use of Eliquis. Clinical Record 9: The patient elected the hospice benefit on 01/20/2024 and was discharged on 02/17/2024. The RN Admission assessment documented on 01/20/2024 included that the patient had a colostomy bag, had a peg tube and was receiving 4-5 cans of Isosource 1.5 formula via peg tube by bolus per day, and had stage 2 pressure wounds on the right and left buttock requiring daily dressing changes with wound cleanser, application of antibiotic ointment, covered with gauze, and secured with tape. The patient’s plan of care did not include the identification of problems with related interventions for the colostomy, the peg tube or peg tube feedings, or wounds. Personnel Record 2: During an interview with the Director of Nursing on 03/08/2024 regarding Clinical Records 3 and 4, it was confirmed that the nurse had not completed her admission documentation nor was there a development of any identified problems or related interventions based on their assessment data. The Administrator and the Office Coordinator were interviewed on 03/08/2024 regarding the absence of developed problems and interventions related to identified and documented data from the patients’ assessments. No further documentation was provided prior to the end of the site visit.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the patient’s revised plan of care included updates from each Interdisciplinary Group member or progress toward goals documented. The agency policy “Interdisciplinary Group” dated 01/31/2015 included in part that “The IDG members will meet...at a minimum of every 15 days to review and update the patient’s written plan of care... The meeting will include ...reports on all care, treatment and services provided since the previous meeting ... included but not limited to problem(s), goal, interventions, outcome/progress toward goals .... the discussion and updates will be documented on the plan of care ...” The hospice policy “Assessments” dated 01/31/2015 included in part that “...The hospice will ensure the update of the comprehensive assessment will be accomplished by the hospice interdisciplinary group ... include information on the patient’s progress toward desired outcomes, as well as reassessment of the patient’s response to care...” Clinical Record 9: The patient elected the hospice benefit on 01/20/2024 and was discharged from hospice on 02/17/2024. The Interdisciplinary Group Meeting (IDG) documentation dated 01/25/2024, 02/08/2024, and 02/22/2024 included no notes or updates from the Nurse or Social Worker and no progress toward goals. Personnel Record 1: During an interview with the Administrator and the Office Coordinator on 03/08/2024 it was confirmed, and no further documentation was produced to provide documentation of Nurse and Social Work updates to the comprehensive plan of care during the Interdisciplinary Group meetings or documentation of progress toward identified goals.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 9 (22%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency did not ensure that the Hospice Aide visits matched the Hospice Aide visit frequency orders in the Plan of Care. Agency policy “Hospice Aide Services” with the effective date of 01/31/2015 included in part that “The RN, who is a member of the Interdisciplinary Group (IDG) and responsible for the hospice aide .... A hospice aide provides services that are ordered by the physician. The physician’s order must indicate the frequency of the home health aide services ... services will be consistent with the plan of care...” Clinical Record 2: The patient elected the hospice benefit on 05/22/2022. A Plan of Care Order dated 11/15/2023 (effective dates of 11/11/2023 to 01/09/2024, a Plan of Care Order dated 12/28/2023 (effective dates of 11/11/2023 to 01/09/2024), and a Plan of Care Order dated 01/11/2024 (for effective dates of 01/10/2024 to 03/09/2024) included no orders for Hospice Aide services. The Interdisciplinary Group Meetings (IDG) documentation dated 11/29/2023, 12/14/2023, 12/27/2023, 01/11/2024, 01/25/2024, 02/08/2024, and 02/22/2024 included no physician orders for Hospice Aide services. There were no new physician orders documented after 11/29/2023. A review of the clinical record revealed hospice aide visits documented twice a week from the week of 12/10/23 to present. Clinical Record 14: The patient elected the hospice benefit on 10/18/2019 and passed on hospice on 09/27/2023. A Plan of Care Order dated 08/09/2023 (effective 07/29/2023 to 09/26/2023) included no Hospice Aide frequency orders. In all Interdisciplinary Group Meetings from 08/09/2023 to the patient’s passing on 09/27/224 it was documented in an Activities of Daily Living care plan that Hospice Aide services were declined. Hospice aide visits were documented once a week beginning the week of 08/06/2023. During an interview with the Administrator and the Office Coordinator on 03/07/2024 and 03/08/2024 the Hospice Aide visits were performed without orders on the plan of care. The Director of Nursing assumed the clinical leadership position in January, was in the field seeing patients as she was also the RN Case Manager, and an interview on 03/08/2024, did not seem to be knowledgeable about agency processes or documentation requirements.”

“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 and interview. In 1 of 1 (100%) clinical record reviewed in which a live discharge occurred revealed the agency did not ensure that the discharge summary was forwarded to the hospital that received the hospice patient. Clinical Record 9: The patient elected the hospice benefit on 01/20/2024 and was discharged from hospice on 02/17/2024. The Hospice Nurse documented in a Live Discharge note on 02/17/2024 that the patient’s daughter took the patient to the hospital. Nothing was documented in the Nurse’s note, in a communication note, in the Interdisciplinary Team Meeting, or scanned into the patient’s clinical record indicating that the Discharge Summary or any clinical information was forwarded to the hospital or the patient’s attending physician. During an interview with the Administrator and the Office Coordinator on 03/08/2024, it was confirmed that the clinical record included no documentation that any of the patient’s clinical information was forwarded to the hospital, to the patient’s physician, or provided to the patient. The Office Coordinator stated that upon discharge from the hospital, the patient/patient’s family contacted another hospice that requested the patient’s information. None of this was recorded in the clinical record.”

“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 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 and interview. In 1 of 1 (100%) clinical records reviewed in which there was a live discharge from the hospice revealed the agency’s discharge summary did not include any clinical information. Clinical Record 9: The patient elected the hospice benefit on 01/20/2024 and was discharged from the agency on 02/17/2024. On 02/17/2024, the Nurse documented in a Live Discharge visit the date of discharge, the stable condition, and the comment that the patient was taken to the hospital via an ambulance. There was no other discharge information and no noted discharge summary form. There was no documentation that the patient’s Plan of Care or physician orders were forwarded to the hospital or the attending physician. During an interview with the Administrator and the Office Coordinator on 03/08/2024, it was confirmed that the only discharge documentation was the Registered Nurse’s (RN) Live Discharge note. There was no Discharge Summary and the RN’s note did not include the required information, nor was there documentation that any clinical information was forwarded to the hospital, to the patient’s physician, or provided to the patient.”