Sahara Hospice Care LLC

“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 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the IDG team completed an initial assessment no later than 5 days after the election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 08/09/2024 with a diagnosis of Vascular Dementia. There was no social work visit documented in the clinical record. Upon further review of the record there was no documented evidence of an initial psychosocial assessment and not documentation explaining why the visit was not competed. An internal audit was conducted by a consultant where this issue was identified, and a performance improvement plan has been initiated with follow up from the consulted to occur on 09/03/2024, 09/17/2024, and 10/08/2024.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); The patient or patient representative if any of them so desire; The primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that a plan of care was written by the IDG group. Clinical Record 2: The patient elected the hospice benefit on 08/09/2024 with a diagnosis of Vascular Dementia. The Director of Nursing stated that on admission a plan of care was written as if a doctor’s order and sent to the doctor for signature, then the plan of care is generated at the first IDG meeting after admission. This should have taken place on 08/26/2024. During review of the clinical record there was no documented evidence of a plan of care or IDG meetings completed. The director of nursing stated that the EMR has been having some issues and making updates that have affected some documentation to show up. She stated that she and the consultant are working with EMR vendor to resolve these issues.”

“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 as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the IDG group did not review, revise, or document the individualized care plan no less frequently than every 15 days or as the patient’s condition requires it. Clinical Record 1: The patient elected the hospice benefit on 08/19/2024, with a diagnosis of Alzheimer’s Disease. The clinical record review revealed documented evidence of a care plan and an IDT meeting on the same date. However, no further documentation of any subsequent IDT meetings or updated care plans was found. In an interview, the Director of Nursing indicated that documentation from an IDT meeting held on 08/30/2024, should be present in the record, yet no such documentation was located. Clinical Record 2: The patient elected the hospice benefit on 08/09/2024. During review of the clinical record there was no documented evidence of an IDT meeting taking place for this patient. In an interview with the director of nursing, she stated their IDG meeting took place on 08/16/2024 and 08/30/2024 with the next one due on 09/13/2024. She was unable to provide the documentation for 08/16/2024 or 08/30/2024.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed revealed that the agency did not ensure specific instructions were included on the aide plan of care. Clinical Record 1: The patient elected the hospice benefit on 08/19/2024 with a diagnosis of Alzheimer’s disease. The patient had aide services ordered on the plan of care for 3 times a week. The plan of care developed and written by the RN included as needed tasks for foot care, back rub, nail care, partial bath or shower, shave, assist with bedpan and assist with bedside commode. The aide care plan lacked specific instructions for the aide. Clinical Record 3: The patient elected the hospice benefit on 08/20/2024 with a diagnosis of Alzheimer’s disease. The plan of care ordered aides 5 times a week. The plan of care developed and written by the RN included as needed tasks for foot care, back rub, nail care, partial bath or shower, shave, light housekeeping, assist with bedpan and assist with bedside commode. The aide care plan lacked specific instructions for the aide. During the joint record review and interview with the clinical manager, she said they did use the as needed orders.”

“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. The patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical record reviewed revealed that the agency did not ensure that the clinical record included physician orders. Clinical Record 2: The patient elected the hospice benefit on 08/09/2024 with a diagnosis of Vascular Dementia. On the initial RN comprehensive assessment, the RN documented assessment of wounds and wound care completed, “On the left buttock area, the patient has some scattered stage 2 pressure injuries. SN cleansed the area with normal saline and applied hydrocolloid dressing over it. The skin tear on the left elbow measures 2 cm X 1.0 cm X 0.1 cm and the right-hand skin tear measures 1.5 cm X 1.0 cm X 0.1 cm. SN cleansed the area with the normal saline, applied triple antibiotic and covered with foam dressing. Patient tolerated it well.” During further review of the clinical record there was no evidence of a physician’s order for wound care. In an interview with the director of nursing she stated the order should have been in the chart or listed on the plan of care.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record of a discharged patient revealed that the agency did not ensure that the discharge summary or patients record was forwarded to the receiving facility. THIS IS A CONTINUED REQUIRED ACTION Clinical Record 5: The patient elected the hospice benefit on 08/21/2023 with a diagnosis of Alzheimer’s Disease. On 08/29/2024 the family made the decision to revoke hospice services due to the patient was sent to the hospital for aggressive treatment. There was no documented evidence that the agency made any communication with the hospital or that a discharge summary had been sent. During the interview with the director of nursing she stated that the patient went to the hospital for IV antibiotics, and she could not provide any documentation that report was called or that any documents were sent to the receiving facility. THIS IS A CONTINUED REQUIRED ACTION”

“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 1 (100%) clinical record that was discharged revealed that the agency did not ensure that a discharge summary was completed. THIS IS A CONTINUED REQUIRED ACTION Clinical Record 5: The patient elected the hospice benefit on 08/21/2023 with a diagnosis of Alzheimer’s Disease. On 08/29/2024 the family made the decision to revoke hospice services due to the patient was sent to the hospital for aggressive treatment. There was no documented evidence that the agency completed a discharge summary including 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 requested. In an interview with the director of nursing she was unable to provide documentation of a discharge summary for this patient. During the interview with the director of nursing she stated that the patient went to the hospital for IV antibiotics, and she could not provide any documentation that report was called or that any documents were sent to the receiving facility. THIS IS A CONTINUED REQUIRED ACTION”

“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. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by a review of clinical records, document review, and interview which revealed the hospice: Failed to ensure the patients had a volunteer needs assessment, and volunteer plan of care with task for the volunteers to perform {HCDT.21. I/L644}. 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 documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs. 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 document review, interview and observation. In 2 of 14 (14%) medication profiles for active hospice patients reviewed revealed that the hospice agency did not ensure that the patient’s drug profile contained the patient’s current prescription and over-the-counter drugs. The hospice agency did not ensure the patient’s drug profile was updated per the hospice policy and procedure. Document 2: Policy 8.20.1 (Revised June 2019), titled, Medication Reconciliation, stated in part, medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list will be updated with each new or changed medication. Home Visit 1: The hospice election of benefit was 04/19/2023 and the patient resided in an assisted living facility (ALF). During the home visit (Home Visit 1, Clinical Record 1) with the Chaplain (Personnel Record 7) on 07/25/2024 the medication profile was reviewed. The agency medication profile listed an Acetaminophen rectal suppository of 650 mg per rectum every six hours as needed for pain and Lorazepam oral 0.5 mg every 2-3 hours as needed for anxiety. The medications were ordered on 12/15/2022. The Acetaminophen and Lorazepam was not listed on the facility medication profile. Home Visit 2: The hospice election of benefit was 04/01/2024 and the patient resided in an assisted living facility (ALF). During the home visit (Home Visit 2, Clinical Record 2) with the registered nurse (RN) (Personnel Record 6) on 07/25/2024, The hospice medication profile reviewed on 07/25/2024 listed Lasix oral 20 mg daily at 9 am. The medication was ordered on 07/02/2024. The hospice medication profile listed Atropine Sulfate Ophthalmic Solution 1% give one drop under the tongue once daily as needed and Rytary oral extended release 48.75-195 mg at 8 am, 12 pm, 4 pm, and 8 pm. Both the Atropine and Rytary were ordered on 06/21/2024. The Lasix, Atropine, and Rytary medications were not listed on the facility medication profile. During an interview on 07/25/2024, the Director of Nursing agreed the medication profiles has not been reconciled.”

“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. Volunteer services are: Noted in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 4 (50%) clinical records reviewed for patients receiving volunteer services revealed that the hospice agency did not ensure the patients had a volunteer needs assessment, and volunteer plan of care with task for the volunteers to perform. Document 2: Agency 4.24.3., titled, Volunteer Services, stated in part, volunteer duties may include patient care activities that must be evident in the patient’s plan of care. Patient care activities allowed are emotional support, companionship and practical assistance, errands, meals, housekeeping tasks, and minimum patient comfort measures and transportation. Clinical Record 1: The patient elected the hospice benefit on 04/19/2023. Volunteer services were ordered on 05/13/2024 at a frequency of once a quarter. The patient received volunteer visits on 05/16/2024 and 05/30/2024. The patient volunteer documented that the patient’s nails were cut, new colors polished, and massaged hands. There was no documented evidence that the volunteer coordinator completed a volunteer needs assessment, no volunteer assigned task for the volunteer to complete on the patient volunteer visits and was not included in the plan of care. Clinical Record 2: The patient elected their hospice benefit on 04/01/2024. Volunteer services were ordered on 04/01/2024 at a frequency of one time a month. The patient has received volunteer visits on 04/09/2024 and 06/04/2024. The patient volunteer documented that the patient’s nails were cut and massage oil was applied to the patient’s arms and legs. There was no documented evidence that the volunteer coordinator completed a volunteer needs assessment, no volunteer assigned task for the volunteer to complete on the patient volunteer visits and was not included in the plan of care. During an interview on 07/26/2024, the Administrator/Volunteer Coordinator agreed that the patient volunteer had been cutting the patient’s nails as documented in the clinical records. The Administrator/Volunteer Coordinator also stated he would be educating the patient volunteer on what allowable tasks a patient volunteer may perform with the patients.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical records reviewed for patients transferred to another Medicare/Medicaid-certified facility revealed that the hospice agency did not ensure a copy of the hospice discharge summary was forwarded to the receiving Medicare/Medicaid-certified facility. Document 3: Policy 9.29.1 (Revised 2019), titled, Discharge Summary, stated in part, if the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice will forward, to the receiving facility, a copy of the hospice discharge summary. Clinical Record 12: The patient elected their hospice benefit and start of care on 08/18/2023. The patient was discharged from the hospice agency due to transferring to Medicare/Medicaid certified facility on 09/26/2023. The clinical record included a documented live discharge note dated 09/26/2023. There was no documented evidence that a hospice discharge summary was completed and forwarded to the receiving facility, During an interview on 07/26/2024, the Director of Nursing agreed that a discharge summary had not been completed or forwarded to the receiving facility. The Director of Nursing stated that the receiving facility transferred the patient without them being made aware until a week later.”

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical records reviewed for patients discharge revealed that the hospice agency did not ensure that the hospice discharge summary was completed and included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Document 2: Policy 9.29.1 (Revised June 2019), titled, Discharge Summary, stated in part, that the hospice discharge summary will include a summary of the patient’s stay including treatments, symptoms, and pain management. Clinical Record 12: The patient elected their hospice benefit and start of care on 08/18/2023. The patient later transferred to another hospice on 09/26/2023. There was no documented evidence that the hospice discharge summary had been completed. During an interview on 07/26/2024, the Director of Nursing agreed that the hospice discharge summary had not been completed.”