Mt. Sinai Hospice

“It is required the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization, THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice failed to ensure that the Registered Nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care [HCPC.19.I/L540]; Failed to ensure that all hospice care and services furnished to patients followed an individualized written plan of care [HCPC.91.I/L543]; Failed to ensure that an individualized written plan of care was prepared for each patient based on the comprehensive assessment [HCPC.21.I/L545]; and Failed to document a statement of the scope and frequency of social work services necessary to meet the specific patient and family needs [HCPC.21.I/L547]. 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: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“The hospice implements emergency preparedness (EP) policies and procedures based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment. The minimum information provided to facilitate patient evacuation and transportation including if the patient is mobile or not, if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. 19 of 19 (100%) clinical records reviewed revealed that the agency did not include the required components of an emergency assessment for each patient that provided data on mobility, equipment, or special needs to facilitate evacuation in the event of a disaster. Document 1: Emergency Preparedness and Response Plan (EC.40) 7/1/2023 “... Staff will provide and discuss with the patient and their family information on what to do in a disaster. All patient and family education will be documented in the medical record...Coordination of patient care will include IDG/IDT review and update of classification in the triage system at least every 15 days or when there are significant changes in the patient’s condition. The Hospice will assist with the completion of individual emergency plans for each patient that will be included as part of their comprehensive patient assessment.” Clinical Record 1: The patient elected the hospice benefit on 9/15/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. In the Admission Packet a form was completed that included “...in case of emergency, agency’s responsibilities to you are based on your triage status, but would include [box checked] visit...In the event of a natural disaster...the hospice will prioritize visits according to the following...Triage Level 3: Visits could be postponed 24-48 hours without adverse effects...transportation available from family or friends...In the event of a Disaster, Patient/Family may also call 211, provided by the ‘state”. This will connect you to assistance with information on local shelter and transportation.” Clinical Record 2: The patient elected the hospice benefit on 4/8/2023. In the Admission Packet a form was completed that included “...in case of emergency, agency’s responsibilities to you are based on your triage status, but would include [box checked] visit...In the event of a natural disaster...the hospice will prioritize visits according to the following...Triage Level 3: Visits could be post-poned 24-48 hours without adverse effects...transportation available from family or friends...In the event of a DIsaster, Patient/Family may also call 211, provided by the ‘state”. This will connect you to assistance with information on local shelter and transportation.” Clinical Record 3: The patient elected the hospice benefit on 3/1/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 4: The patient elected the hospice benefit on 5/22/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 5: The patient elected the hospice benefit on 1/24/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 6: The patient elected the hospice benefit on 6/16/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 7: The patient elected the hospice benefit on 1/19/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 8: The patient elected the hospice benefit on 7/26/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 9: The patient elected the hospice benefit on 5/4/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 10: The patient elected the hospice benefit on 7/12/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 11: The patient elected the hospice benefit on 8/1/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 12: The patient elected the hospice benefit on 9/11/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 13: The patient elected the hospice benefit on 3/15/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 14: The patient elected the hospice benefit on 8/31/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 15: The patient elected the hospice benefit on 9/5/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 16: The patient elected the hospice benefit on 9/17/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 17: The patient elected the hospice benefit on 4/18/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 18: The patient elected the hospice benefit on 1/6/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. Clinical Record 19: The patient elected the hospice benefit on 10/2/2023. The Emergency Form completed during admission did not contain information about the patient’s level of mobility, if the patient required life-sustaining equipment, or any particular special needs of the patient, such as cognitive issues, speech/language barriers, or any issues with hearing or sight. The Administrator, alternate and clinical staff will ensure that the current list of patients is maintained, prioritized by care needs, and based on specific services provided. Staff will contact patients according to patient triage prioritization. Staff will visit all patients as possible, based on time, disaster, and Plan of Care. The Hospice’s written emergency preparedness and response plan will include procedures to triage patients that allow the Hospice to categorize patients into groups based on the availability of someone to assume responsibility for a patient’s emergency response plan if needed by the patient Personnel Record 2: During an interview with the Director of Nursing (Staff 2) and the Quality Nurse on 11/9/2023, it was confirmed that the clinical record does not include an emergency plan for each patient.”

“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. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that all members of the Interdisciplinary Group completed their initial assessments within the 5-day timeframe. Clinical Record 2: The patient elected the hospice benefit on 4/8/2023. The RN initial assessment was completed on 4/8/2023 and did not include the psychosocial assessment. The initial social work assessment was performed on 4/15/2023, 7 days after the patient’s admission to hospice care and outside the five-day regulatory period. Personnel Record 2: During an interview with the Director of Nursing (Staff 2) on 11/8/2023, it was confirmed that the Initial social work assessment was performed 7 days after admission and that there was no Interdisciplinary Group Communication, no Communication Note, and no documentation within the initial social worker’s assessment to explain the delay in the first 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, document review and interview. 5 of 19 (26%) clinical records reviewed that the agency did not ensure documentation of care coordination in the patient’s clinical record for all services ordered and/or provided to the patients. Document 1: The agency policy, “Coordination of Care” (PC.110) dated 10/1/2021 read, “...The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, by the Hospice, or by other providers... The Hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated, coordinated plan of care, achieving unduplicated services, and facilitating effective coordination of patient services.” “The designated Registered Nurse (RN) will coordinate care with the Interdisciplinary Group/Team (IDG/IDT) to ensure implementation of the Plan of Care (POC) ...The IDG/IDT will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities... The IDG/IDT will ensure that the care and services provided are based on all assessments of the patient’s and family’s needs and are provided in accordance with the POC. All communications and coordination of care is documented in the clinical record.” Clinical Record 1: The patient elected the hospice benefit on 9/15/2023. There was a visit note from a contracted agency providing wound care scanned into the patient’s medical record for the date of 9/22/2023.There was no coordination of care note or update regarding the wound care specialists documented during the Interdisciplinary Group Meeting/Plan of Care updates for10/4/2023 or 10/18/2023. 11/1/2023. Clinical Record 2: The patient elected the hospice benefit on 4/8/2023.There was a physician’s order dated 4/14/2023 for volunteer services effective for the week beginning 4/9/2023. The social worker documented a communication note on 4/14/2023 stating that volunteer services were accepted and to begin the week of 4/9/2023 and then included, “...see MSW assessment and plan of care...” The Interdisciplinary Group Meeting (IDG)/Plan of Care update for 4/26/2023 documented that “volunteer services were offered. Volunteer orders were received, “but the “CG declined volunteer services at this time.” Interdisciplinary Group Meeting/Plan of care updates for the dates of, 5/10/2023, 5/24/2023, 6/7/2023, 6/21/2023, 6/21/2023, and 7/5/2023 documented that “volunteer services were offered. Volunteer orders were received, “ but the “CG declined Volunteer services at this time.” The documented IDG meetings did not include information about volunteer visits. The Interdisciplinary Group Meeting (IDG)/Plan of Care Updates for the dates 4/12/2023, 4/26/2023, 5/10/2023, 5/24/2023, 6/7/2023, 6/21/2023, 6/21/2023, and 7/5/2023 included an order for social work visits to be performed monthly. There was only one social work visit documented on 4/14/2023. In the IDG Meeting documentation on 4/12/2023, the social worker noted that social work services were declined at admission. However, the IDG updates documented visits on 4/26/2023, and 5/10/2023, the Social Worker included notes indicating that the social worker would provide brief counseling and foster a safe living environment. Then the IDG Updates from 5/24/2023 forward documented that social work services were declined at admission. There was no evidence of and order to discontinue social work visits. Clinical Record 11: The patient elected the hospice benefit on 8/1/2023. A physician’s order was documented on 8/2/2023 for physical therapy (PT) to evaluate and treat the patient. There was no evidence in the patient’s clinical record of the PT visits to the patients. The Interdisciplinary Group Meeting/Plan of Care updates for 8/2/2023, 8/16/2023, 8/30/2023, 9/13/2023, 9/27/2023, 10/11/2023, 10/25/2023, or 11/8/2023 included no coordination notes about Physical Therapy visits to the patient. Clinical Record 17: The patient elected the hospice benefit on 4/18/2023. There was a Physician Order dated 5/22/2023 for Physical Therapy to evaluate and treat the patient. Also, on 5/22/2023, there was a communication note documented by the nurse that the patient’s caregiver wished to have a physical therapist evaluate the patient and help the patient gain strength for an upcoming trip. The Interdisciplinary Group Meetings/Plan of Care Updates for 5/31/2023, 6/14/2023, 6/28/2023, 7/12/2023, 7/26/2023, 8/9/2023, 8/23/2023, 9/6/2023, 9/20/2023, 10/4/2023, 10/18/2023, 11/1/2023 included no documentation of Physical Therapy (PT) visits, no orders for how often the PT visits would occur, and no identified problem, interventions, or goals for PT visits. Wound Care reports from an outside wound care agency for the dates 5/3/2023, 5/10/2023, 5/17/2023, 5/26/2023, 5/31/2023, 6/9/2023, 6/21/2023, 6/28/2023, 7/7/2023, 7/19/2023, 8/2/2023, 8/16/2023, 8/23/2023, 8/30/2023, 9/6/2023 were scanned into the clinical record. The Interdisciplinary Group Meetings/Plan of Care Updates for 5/3/2023, 5/17/2023, 5/31/2023, 6/14/2023, 6/28/2023, 7/12/2023, 7/26/2023, 8/9/2023, 8/23/2023, 9/6/2023, 9/20/2023, 10/4/2023, 10/18/2023, 11/1/2023 included no documentation of any referral order for an outside agency to provide wound care to the patient, no orders for how often the wound care providers would visit the patient, no orders for the wound care itself, and under the identified Skin Integrity issue, there was no intervention related to outside wound care specialists assisting in the patient’s care. Clinical Record 18: The patient elected the hospice benefit on 1/6/2023. A physician’s order was documented 9/13/2023 for physical therapy to evaluate and treat the patient. The nurse noted that the patient was receiving physical therapy services in the Interdisciplinary Group Meeting/Plan of Care Update for 10/4/2023. There was no documentation of physical therapy visit notes found in the patient’s clinical record. The Director of Nursing logged into a separate portal and was able to obtain the visit notes. There were no coordination/updates on the physical therapy visits in Interdisciplinary Group Meeting/Plan of Care Updates for meetings on 9/20/2023, 10/18/2023, and 11/1/2023 Personnel Record 2: It was confirmed In interviews with the Director of Nursing on 11/8/2023 and 11/9/2023, that there was no documented coordination of care in the clinical records for Volunteer visits, Physical Therapy visits, and/or Wound Care visits.”

“It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. 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). This standard was not met, as evidenced by clinical record review, document review, and interview. 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that physician’s orders were documented for wound care or physical therapy services provided by contracted staff. Document 1: The agency policy “Timelines” (IM.40) dated 10/1/2021 included that Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders...Physician signatures are obtained on the IDG/IDT POC by the physician...” Clinical Record 1: The patient elected the hospice benefit on 9/15/2023. The clinical record contained a scanned visit note dated 9/22/2023 completed by the contracted wound care specialist. There was no evidence of a physician’s order for a referral for a wound care consult. Clinical Record 17: A physician’s order was documented on 5/22/2023 for physical therapy (PT) to evaluate and treat the patient. The record did not contain a physician order for the PT visit frequency. The Director of Nursing logged into a separate portal from the contracted agency and identified visit notes for 6/1/2023, 6/3/2023, 6/8/2023, 6/15/2023, and 6/16/2023. The PT notes revealed that the patient received one PT visit for the first week, then twice weekly PT visits for three weeks. There was no order documenting the frequency of PT visits to the patient in the clinical record. Additionally, the clinical record contained scanned wound care reports for the dates 5/3/2023, 5/10/2023, 5/17/2023, 5/26/2023, 5/31/2023, 6/9/2023, 6/21/2023, 6/28/2023, 7/7/2023, 7/19/2023,8/2/2023, 8/16/2023, 8/23/2023, 8/30/2023, and 9/6/2023. There was no physician order for a referral to a wound care specialist consult, wound care, and visit frequency. Clinical Record 18: The patient elected the hospice benefit on 1/6/2023. A physician’s order was documented 9/13/2023 for physical therapy (PT) to evaluate and treat the patient. The nurse reported that the patient was receiving physical therapy services in the Interdisciplinary Group Meeting/Plan of Care update for 10/4/2023. The clinical record did not contain an order documenting the PT visit frequency. Personnel Record 2: During interviews with the Director of Nursing (Staff 2) on 11/8/2023 and 11/9/2023, it was confirmed that there were no documented Interdisciplinary orders for the referrals and frequency of visits of the contracted wound care specialist and physical therapy frequencies.”

“It is required that each patient’s individualized written plan of care 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. 5 of 19 (26%) clinical records reviewed revealed the agency did not ensure that each patient’s individualized plan of care included planned interventions based on identified problems as noted in the initial and updated comprehensive assessments. Document 1: The agency policy “Medical Record Content” (IM.30) dated 10/1/2021 read that the patient’s medical record would include, “...Initial and ongoing interdisciplinary plans of care including identification of problems, interventions, goals, and the patient’s response to the POC...” The agency policy “Levels of Care” (PC.120) dated 10/1/2021 included, “...The clinical record ... will include ... Reason for respite care including dates of respite care ...The POC specifying respite services to be furnished..” Clinical Record 1: The patient elected the hospice benefit on 9/15/2023. There was a visit note from an outside agency providing wound care scanned into the patient’s medical record for the date of 9/22/2023.There were no identified interventions related to an outside wound care specialist or specific wound interventions for the Interdisciplinary Group Meeting/Plan of Care updates for 10/4/2023, 10/18/2023, or 11/1/2023, which were not included in the Plan of Care. Clinical Record 2: The patient elected the hospice benefit on 4/8/2023. A Physician Order dated 4/21/2023 was documented for a change in the patient’s level of care to go to Respite Care from 4/21/2023 to 4/23/2023. The Interdisciplinary Meeting/Updated Plan of Care on 4/19/2023 or 5/3/2023 identified no problem or interventions related to respite care or any other documentation as to why the patient was placed in the Respite level of care. Clinical Record 12: The patient elected the hospice benefit on 9/11/2023 with the diagnosis of pulmonary fibrosis. On 10/4/2023, the nurse documented that the patient was short of breath with minimal exertion and was on 2-4 liters/minute oxygen. The patient had respiratory medications profiled for Ipratropium Bromide Inhalation Solution 0.02% every six hours as needed for shortness of breath and Budesonide Formoterol Fumate 160/4.5 mcg/acutation. The Interdisciplinary Group Meetings/Plan of Care Updates for 9/13/2023, 9/27/2023, 10/11/2023, 10/25/2023, and 11/8/2023 did not include any identified respiratory problems or interventions. Clinical Record 17: The patient elected the hospice benefit on 4/18/2023. There was a Physician Order dated 5/22/2023 for Physical Therapy to evaluate and treat the patient. Also, on 5/22/2023, the nurse documented a communication note that the patient’s caregiver wished to have a physical therapist evaluate the patient and help the patient gain strength for an upcoming trip. The Interdisciplinary Group Meetings/Plan of Care Updates for 5/31/2023, 6/14/2023, 6/28/2023, 7/12/2023, 7/26/2023, 8/9/2023, 8/23/2023, 9/6/2023, 9/20/2023, 10/4/2023, 10/18/2023, 11/1/2023 did not include any identified problem or intervention related to Physical Therapy visits. There were wound care reports scanned into the patient’s clinical record for the dates 5/3/2023, 5/10/2023, 5/17/2023, 5/26/2023, 5/31/2023, 6/9/2023, 6/21/2023, 6/28/2023, 7/7/2023, 7/19/2023,8/2/2023, 8/16/2023, 8/23/2023, 8/30/2023, and 9/6/2023. There were not any identified interventions indicating wound care visits or wound care treatment for the patient provided by a contracted wound care specialist. Clinical Record 18: The patient elected the hospice benefit on 1/6/2023. There was a physician’s order dated 9/13/2023 for physical therapy to evaluate and treat. The Interdisciplinary Group Meetings/Plan of Care updates for 9/20/2023, 10/4/2023, 10/18/2023, or 11/1/2023 did not include any identified problems or interventions for the PT visits to the patient. Personnel Record 2: During an interview with the Director of Nursing (Staff 2) on 11/9/2023, a review and discussion of the clinical records confirmed that there were no identified planned interventions related to physical therapy, outside wound care, change in level of care, and the patient’s respiratory problems.”

“It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. In 4 of 19 (21%) clinical records reviewed revealed the agency did not ensure that the scope and frequency of visits for Physical Therapy or Wound Care Specialists were included in the patient’s Plan of Care. Clinical Record 1: The patient elected the hospice benefit on 9/15/2023. There was a visit note from an contracted agency providing wound care scanned into the patient’s medical record for the date of 9/22/2023. There was no order by the Interdisciplinary Group specifying how often the wound care specialists would provide visits to the patient. Clinical Record 11: The patient elected the hospice benefit on 8/1/2023. A physician’s order was documented on 8/2/2023 for physical therapy (PT) to evaluate and treat the patient. There was no order by the Interdisciplinary Group specifying how often the physical therapist would provide visits to the patient. Clinical Record 17: The patient elected the hospice benefit on 4/18/2023. A physician’s order was dated 5/22/2023 for physical therapy to evaluate and treat the patient. There was no order identified by the Interdisciplinary Group specifying how often the physical therapist would provide visits to the patient. Wound care specialist reports were scanned into the patient’s clinical record for the dates 5/3/2023, 5/10/2023, 5/17/2023, 5/26/2023, 5/31/2023, 6/9/2023, 6/21/2023, 6/28/2023, 7/7/2023, 7/19/2023, 8/2/2023, 8/16/2023, 8/23/2023, 8/30/2023, 9/6/2023. There was no order by the Interdisciplinary Group specifying how often the wound care specialist would provide visits to the patient.. Clinical Record 18: The patient elected the hospice benefit on 1/6/2023. A physician’s order was documented 9/13/2023 for physical therapy to evaluate and treat the patient. There was no order by the Interdisciplinary Group specifying how often the physical therapist would provide visits to the patient. Personnel Record 2: It was confirmed In interviews with the Director of Nursing on 11/8/2023 and 11/9/2023, that there was no documentation in the reviewed patients clinical record for the scope and frequency of physical therapy visits or wound care specialist visits.”

“It is required that medical social services are provided according to the patient’s and family’s needs and acceptance of these services and per the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical records reviewed in which social work services were accepted revealed the agency did not ensure that the social work visits were performed per the Plan of Care orders. Clinical Record 2: The patient elected the hospice benefit on 4/8/2023. The Plan of Care Order dated 4/8/2023 for effective dates 4/8/23 - 6/6/2023 included an order for social worker visits once a month. The social worker documented a visit on 4/14/2023. The Interdisciplinary Group (IDG) Meeting/Plan of Care updates for the dates 4/26/2023 and 5/10/2023 included documentation from the social worker that visits would be made to provide for brief counseling, to foster a safe environment...” Then, the social worker documented in the IDG Meeting/Plan of Care updates for 5/24/2023, 6/7/2023, 6/21/2023, and 7/5/2023 that social work services were declined at admission. There was no documented evidence of a physician’s order to discontinue social work visits. The only visit documented by the social worker was on 4/14/2023. There were no missed visits documented, no communication notes regarding the reason for the missed visits. The IDG meeting documentation did not address the missing social work visits and the identified need. Personnel Record 2: The order-to-visit mismatch was confirmed during an interview with the Director of Nursing on 11/8/2023, and it was also verified that there were no Interdisciplinary Group notes and no communication notes explaining the discrepancy.”

“Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by clinical record review and interview. 4 of 8 (50%) applicable clinical records of patients receiving chaplain services identified that services were not provided as ordered in the plan of care in accordance with the patient’s and family’s acceptance of the services. Clinical Record 6: The patient elected the hospice benefit on 6/16/2023 with a diagnosis of Alzheimer’s. The Plan of Care order dated 6/21/2023 included orders for the chaplain “PRN Chaplain visits only” effective dates 6/16/2023 - 8/14/2023. The subsequent Plan of Care order Update dated 7/5/2023 for the effective dates 6/17/2023 - 8/14/2023 increased the chaplain’s frequency of visits to twice a week. This order for twice weekly chaplain visits continued on the Plan of Care order updated dated 8/16/2023 for the effective dates 8/15/2023 - 10/13/2023. From July 5th until August 15th, the chaplain, per orders, should have been visiting the patient twice a week. On August 15th, that was changed to once-a-month visits. Then, on October 11th, the chaplain frequency changed again to twice monthly. Then, the Plan of Care order update dated 10/11/2023 for the effective dates 10/14/2023 - 12/12/2023 decreased the chaplain frequency to twice a month. As of 11/9/2023, there was no documented evidence of chaplain visits for July or August. A chaplain telehealth visit was documented on 9/13/2023. And then, in October, there were visits documented on the 20th and the 31st. The chaplain visits were out of compliance from 7/5/2023 to 8/31/2023. There was no documentation explaining the visit frequency changes. Clinical Record 7: The patient elected the hospice benefit on 1/19/2023 with a diagnosis of Parkinson’s included an order for the or the chaplain to make twice weekly visits effective dates 7/18/2023 - 9/15/2023; and the subsequent Plan of Care update 9/27/2023 for effective dates 9/16/2023 - 11/14/2023. The Plan of Care order dated 8/2/2023 included an order f to the patient. The chaplain documented visits on 9/7/2023, 9/14/2023, 9/21/2023, 10/12/202, and 10/27/23, as well as a missed visit on 9/29/2023. There was no documentation in the Interdisciplinary Meeting/Plan of Care updates for the dates 8/30/2023, 9/13/2023, 9/27/2023, 10/11/2023, 10/25/2023, or 11/8/2023 regarding not following the visit frequency as ordered. There were no communication notes entered to document the reason for the visit discrepancy. Clinical Record 16: The patient elected the hospice benefit on 9/17/2023. The Plan of Care order dated 9/21/2023 for the benefit period 9/17/23 - 12/15/23 included chaplain frequency set three times a week and repeated in the Plan of Care order/IDG Meeting for 9/27/2023 and 10/11/2023. The chaplain made visits on 9/18/2023, 10/14/2023, and 10/16/2023. The week of 9/17/2023, the chaplain made one visit. A missed visit was documented on 10/20/2023. During the weeks of 9/24/2023 - 9/30/2023 and 10/1/2023 - 10/7/2023, there were no chaplain visits documented and no missed visit entries, so there were six missed chaplain visits not documented. One chaplain visit was documented the week of 10/8/2023 - 10/14/2023. There were 2 missing chaplain visits that were not documented. During the week of 10/15/2023 - 10/21/2023, there was one chaplain visit documented and one missed visit documented. So, one missed chaplain visit. The order was changed on 10/25/2023. On 10/25/2023, the chaplain’s frequency was changed to three times a month. There were no communication notes entered to document the reason for the changes in the visit frequency. visit discrepancy. Clinical Record 17: The patient elected the hospice benefit on 4/18/2023. The Plan of Care order dated 4/19/2023 for effective dates 4/18/2023 - 7/16/2023 and the subsequent Plan of Care update for effective dates 7/17/2023 - 10/14/2023 included an order for the chaplain to make monthly visits to the patient. The chaplain documented visits for May 2023, June 2023, and July 2023. There were no chaplain visits for the month of August 2023, no Communication Notes documenting a reason for missed visits, and there was no documentation in the Interdisciplinary Meeting/Plan of Care updates for the dates 7/26/2023, 8/9/2023, 8/23/2023, or 9/6/2023 about any missed Chaplain visits. Personnel Record 2: It was confirmed during an interview with the Director of Nursing on 11/8/2023 and 11/9/2023 that there was a mismatch in the order for the chaplain visits. Further, she explained that as the team enters their frequency orders, the default is to week versus month, which is likely causing the problems.”

“It is required that a 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, document review and interview. 5 of 11 (45%) clinical records reviewed of patients with hospice aide services, the agency did not ensure that the hospice aide received clear and specific written instructions, related to the visit frequency. Document 1: The agency policy “Delegation of Nursing Tasks” (HR.101), dated 5/1/2023, read that “...The nursing task being delegated will not involve the unlicensed person to exercise any nursing judgment.” The hospice policy “Employee Supervision’ (HR.60) dated 10/1/2021 included that, “... Nursing care and services are provided by or under the supervision of a Registered Nurse.” The agency policy “Implementing Care and Treatment” (PC.35) dated 4/4/2023 stated, “...The Hospice RN, who is a member of the IDG/IDT, will oversee the assignment of a Hospice Aide (HA) to a particular patient, initiating hospice aide services within time frame to meet identified patient’s needs as identified in the POC and per physician orders. The HA will be provided with written instructions for patient care prepared by an RN...” Document 2: Per the ‘State’ Administrative Code (Title 22, Part 11, Chapter 225: RN Delegation to Unlicensed Personnel ...Rule 225.3), “...As professional nurses, regardless of practice setting, RNs are obligated to assess the nursing needs of the client, develop a plan of nursing actions, implement this plan, and evaluate the outcome... Professional nursing while inclusive of tasks is not focused on tasks but rather on interventions or client-centered actions initiated to assist the client in accomplishing the goals defined in the nursing care plan. Clinical Record 4: The patient elected the hospice benefit on 5/22/2023. The Plan of Care order dated 6/1/2023 for the benefit period 5/2 /2023 - 8/19/2023 included an order for the Hospice Aide to perform visits three times weekly with the patient. In addition to the weekly frequency of aide visits, there was an order for 3 PRN aide visits. There was no documentation in the orders that described the circumstances for using the prn visits. There was no documented evidence that the RN received clarification on the prn use from the physician. Clinical Record 5: The patient elected the hospice benefit on 1/24/2023. The Plan of Care order dated 1/25/2023 for the benefit period 1/24/2023 - 4/23/2023 included an order for the Hospice Aide to perform visits three times weekly with the patient. In addition to the weekly frequency of aide visits, there was an order for 2 PRN aide visits. There was no documentation in the orders that described the circumstances for using the prn visits. There was no documented evidence that the RN received clarification on the prn use from the physician. Clinical Record 9: The patient elected the hospice benefit on 5/4/2023/2023. The Plan of Care order dated 10/4/2023 for the benefit period 10/1/2023 - 11/29/2023 included an order for the Hospice Aide to perform visits three times weekly with the patient. In addition to the weekly frequency of aide visits, there was an order for 3 PRN aide visits without defining the frequency of the prn visits. There was no documentation in the orders that described the circumstances for using the prn visits. There was no documented evidence that the RN received clarification on the prn use from the physician. Clinical Record 17: The patient elected the hospice benefit on 4/18/2023. The Plans of Care order dated for the benefit periods 4/18/2023 - 7/16/2023, 7/17/2023 - 10/14/2023, and 10/15/2023 - 12/13/2023 included an order for the Hospice Aide to perform visits three times weekly with the patient. In addition to the weekly frequency of aide visits, there was an order for 2 PRN aide visits. There was no documentation in the orders that described the circumstances for using the prn visits. There was no documented evidence that the RN received clarification on the prn use from the physician. Clinical Record 19: The patient elected the hospice benefit on 10/3/2023. The Plan of Care order dated 10/6/2023 for the benefit period 10/2/2023 - 12/30/2023 included an order for the Hospice Aide to perform visits five times weekly with the patient. In addition to the weekly frequency of aide visits, there was an order for 2 PRN aide visits. There was no documentation in the orders that described the circumstances for using the prn visits. There was no documented evidence that the RN received clarification on the prn use from the physician. Personnel Record 2: During an interview with the Director of Nursing (Staff 2) on 11/6/23, she confirmed that there were PRN orders for the Hospice Aide visits and was not aware that Hospice Aides could not have PRN orders.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles and Volunteer Services are noted in the plan of care. This standard was not met, as evidenced by clinical record review, document review, and interview. 1 of 1 (100%) clinical records reviewed that accepted volunteer services revealed that the agency did not ensure that volunteer services provided as consistent with the Plan of Care. Document 1: The agency policy “Volunteers” (HR.95) 10/1/2021 read that, ...”The (IDG/IDT) will assess the need for a volunteer for the patient, family, and/or caregiver... Patient Care Volunteers will report patient, family, and/or care giver response to volunteer services...Volunteers will document services provided to a patient and if applicable, services provided to the patient’s family...” Clinical Record 2: The patient elected the hospice benefit on 4/8/2023. A physician order was documented on 4/14/2023 for Volunteer Services effective 4/9/2023. There was no documented evidence of volunteer visit notes in the patient’s clinical record. There were no updates provided in the Interdisciplinary Group Meetings dated 4/26/2023, 5/4/2023, 5/10/2023, 5/31/2023, 6/2/2023, 6/12/2023, or 6/30/2023. The patient died while on hospice services on 7/5/2023. The clinical record did not contain an order to discontinue Volunteer services. Personnel Record 2: During an interview with the Director of Nursing (Staff 2) on 11/8/2023, it was confirmed that there was no documented follow-up on the order for volunteer services in the patient’s clinical record.”

“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. Each patient’s record includes, at a minimum the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review and interview. 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that the physical therapy progress visit notes were in the clinical record. Document 1: The agency policy, “Timelines” (IM.40) dated 10/1/2021, read that, “All clinical and progress notes will be written the day service is rendered and incorporated into the patient’s medical record within 14 working days.” Clinical Record 11: The patient elected the hospice benefit on 8/1/2023. A physician’s order was documented on 8/2/2023 for physical therapy (PT) to evaluate and treat the patient. The clinical record was missing a physical therapy evaluation and visit note(s) provided by the contracted PT. There was no documentation explaining the status of the physical therapy that was ordered.. Clinical Record 17: The patient elected the hospice benefit on 4/18/2023. A physician’s order was documented on 5/22/2023 for physical therapy (PT) to evaluate and treat the patient. The clinical record was missing a physical therapy evaluation and visit note(s) provided by the contracted PT. There was no documentation explaining the status of the physical therapy that was ordered. The Director of Nursing (DON) logged into a separate portal and was able to obtain PT visit notes for 6/1/2023, 6/3/2023, 6/8/2023, 6/15/2023, and 6/16/2023. The DON explained that the contracted PT company sent the notes in a portal, that had not yet been integrated into the hospice’s clinical record. Clinical Record 18: The patient elected the hospice benefit on 1/6/2023. A physician’s order was documented on 9/13/2023 for physical therapy (PT) to evaluate and treat the patient. The nurse noted that the patient was receiving physical therapy services in the Interdisciplinary Group Meeting/Plan of Care Update for 10/4/2023. There was no evidence in the patient’s clinical record of the PT visits to the patients. The Director of Nursing logged into a separate portal and was able to obtain visit notes for 9/15/2023, 9/20/2023, 9/22/2023, 9/25/2023, 9/28/2023, 10/3/2023, 10/5/2023, 10/9/2023, and a missed visit documented for 10/14/2023. Personnel Record 2: During an interview with the Director of Nursing (Staff 2) on 11/8/2023, it was confirmed that the Physical Therapy notes were obtained from a separate portal and hadn’t been uploaded to the patient’s 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 the 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. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed in which live discharges occurred, the discharge summary did not include information to assist in continuity of care. Clinical Record 1: The patient elected the hospice benefit on 9/15/2023, and the family/caregiver signed a statement of revocation on 10/1/2023. The discharge summary was sent on 9/15/2023. There was no documented evidence that the discharge summary included information about the symptom management the hospice was providing during her hospice stay and current medications at the time of discharge. The discharge summary did not include the plan of care and physician orders. Personnel Record 2: During an interview with the Director of Nursing (Staff 2) on 11/9/2023, it was confirmed that the patient’s discharge summary did not include any information on the patient’s hospital stay, medications, symptom management, or Plan of Care; and there was no documentation that any of this added that the staff did hand carry and deliver to two providers an update that the patient had revoked services and the discharge summary, but none of the required information was included in the record.”