Calvert Hospice LLC

“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 Plan of Care was updated with planned interventions based on updated assessment data. (HCPC.21. I/L545}; and Failed to ensure that each patient’s Plan of Care included measurable outcomes related to the implementation of the Plan of Care {HCPC.21. I/L548}; and Failed to ensure that all members of the Interdisciplinary Group documented review, revision, and update of the patient’s Plan of Care at least every 15 days {HCPC.21. I/L552}. 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 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that the Interdisciplinary Group completed the initial comprehensive assessment within the 5 days after the start of care. Clinical Record 7: The patient elected the hospice benefit on 12/29/2023. The Initial Social Worker Assessment was not documented until 01/15/2024, sixteen days after the start of care. The Initial Chaplain Assessment was not documented until 01/05/2024, seven days after the start of care. There was no explanation for the delay in the Chaplain and Social Worker’s initial visits a communication note, in the Interdisciplinary Team Meetings on 12/29/2023 or 01/12/2024, or either one of the clinician’s assessment notes. During the joint clinical record review and interview with the Administrator (Staff 1) on 03/29/2024, it was confirmed that there was no documentation in the clinical record as to why the Social Worker and the Chaplain did not document their initial assessments within the five days after the patient’s admission.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed revealed the agency did not ensure that the hospice documented an initial Bereavement RISK Assessment as part of the patient’s initial Comprehensive Assessment. The agency policy “Bereavement Support and Services” (DOC ID: 3.10.1) with the revised date of 03/22/2022 read in part that “...Patients and significant others ... are assessed for grief and bereavement needs from admission ...The patient’s grieving response is evaluated to identify issues that may complicate the patient’s life closure. A survivor risk assessment tool is utilized. Each assessment and reassessment document the patient/family/caregiver’s needs and goals related to bereavement...” Clinical Record 1: The patient elected the hospice benefit on 08/11/2023. The Initial Registered Nurse Admission visit was documented on 08/11/2023, and the Initial Chaplain Assessment was documented on 08/14/223. Neither visit included a bereavement risk assessment, and there was no initial Social Worker assessment. The Interdisciplinary Team Meeting on 08/11/2023 did not include a bereavement risk assessment. Clinical Record 2: The patient elected the hospice benefit on 10/24/2023. The Initial Registered Nurse Admission visit documented on 10/24/2023 did not include a bereavement risk assessment, and there were no initial Social Worker or Chaplain assessments. The Interdisciplinary Team Meeting on 11/02/2024 also did not include a bereavement risk assessment. Clinical Record 6: The patient elected the hospice benefit on 12/19/2023. The Initial Registered Nurse Admission visit documented on 12/19/2023 did not include a bereavement risk assessment, and there were no initial Social Worker or Chaplain assessments. Similarly, the interdisciplinary team meeting on 12/29/2024 did not include a bereavement risk assessment. It was confirmed during a joint record review and interviews with the Administrator (Staff 1) and the Clinical Director (Staff 2) on 03/28/2024 and 03/29/2024 that clinical records 1, 2, and 6 did not have an initial bereavement risk assessment documented as part of the initial Comprehensive Assessment.”

“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. In 11 of 19 (58%) clinical records reviewed revealed the agency did not ensure that the patient’s Registered Nurse ensured continuous assessment of each patient or the implementation of the patient’s Plan of Care as stated in agency policy. The hospice’s policy “Interdisciplinary Team” (DOC ID: 3.12.1) with the revised date of 03/22/2022 included in part that “The IDT involved in the care of the patient consists of ...Registered Nurse/Case Manager, the patient’s attending physician, the Medical Director, Social Worker, Pastoral, Chaplain, or Counselor, Aide/homemaker, Volunteer/Volunteer Coordinator, Bereavement Coordinator/counselor, a pharmacist and nutritionist, therapists: physical, occupational, speech...A Registered Nurse who is a member of the Interdisciplinary Group provides coordination of care and ensures continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary Plan of Care ... These meetings are documented and may include ...developing and modifying the patient/family care plan,... evaluating current services for effectiveness... evaluating patient outcomes and revising goals as needed...The Interdisciplinary Team ... Reviews and updates the Plan of Care for each patient/family receiving hospice care at a minimum of every two weeks ... The nurse coordinates the Plan of Care ...acts as a liaison between the DIT members to ensure continuous assessment, planning, and implementation of each patient/family’s Plan of Care. Agency policy “Patient Assessment” (DOC ID: 3.17.1) with the revised date of 03/22/2022 read in part that “Persons qualified to perform the assessment functions include: Registered nurses provide a comprehensive health and psychosocial evaluation ...A comprehensive assessment is completed as often as needed but no less than every 14 days ...” Agency policy “Plan of Care” (DOC ID: 3.19.2) with the revised date of 03/22/2022 included in part that “The care provided to the patient/family is in accordance with the POC. Individuals involved in developing the Plan of Care may include ... Registered Nurse...” Reassessment of the Patient (DOC ID: 3.28.2) revised 03/23/2022 The Case Manager nurse provides ongoing assessment of the patient’s physical status, functional activities of daily living, psychosocial, spiritual, and environmental needs, and response to care ...the nurse evaluates the patient/family need for changes in the level of care; updates the medication profile as needed, assessment the patient’s requirements for personal care, assigns, reviews and revises the home care aide assignment as appropriate, documents findings in the patient’s record....” Hospice policy, “Assignment and Supervision” (DOC ID: 3.51.1), with the revised date of 03/23/2022, read in part that “...An RN assesses the patient’s need for hospice services and assigns staff according to patient’s needs with RN maintaining responsibility for overall supervision of the LPNs and the HCAs delivery of care...” The policy “Core Services” (DOC ID: 1.05.1) with the revised date of 03/22/2022 read in part that “...The hospice provides nursing care and services by or under the supervision of a registered nurse. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial, comprehensive, and updated assessments... “ The hospice’s policy, “Coordination of Service” (DOC ID: 3.08.1), with the revised date of 03/22/2022, read in part that “...A registered nurse is assigned to each patient to function as the Case Manager... The Case Manager coordinates care with other disciplines, monitors the patient’s progress, and determines when other disciplines need to be involved in the patient’s care. All professional staff members are responsible for developing and modifying the Plan of Care relative to their discipline.” The agency’s policy “Scheduling” (DOC ID: 3.21.1) with the revised date of 03/22/2022 included in part that “...Visits are scheduled as ordered in the Interdisciplinary Group’s Plan of Care... If a visit is not rescheduled in compliance with the ...Plan of Care (orders), the physician must be notified that the visit was missed, and the fact documented in the patient’s record ...” Clinical Record 1: The patient elected the hospice benefit on 08/11/2023 with the primary diagnosis of Chronic Obstructive Pulmonary Disease. The Plan of Care dated 11/09/2023 (effective 11/09/2023 to 02/06/2024) and the Plan of Care dated 02/07/2024 (effective 02/07/2024 to 04/06/2024) included the frequency of nursing visits three times weekly and monthly Social Work and Chaplain visits. The only Social Work visit documented was on 02/20/2024. There was no Chaplain visit for December 2023. Two nursing visits were missing the week of 01/01/2024. The weeks of 01/08/2024, 02/19/2024, and 03/04/2024 each had one missing nursing visit. There were no missed visits documented. Clinical Record 2: The patient elected the hospice benefit on 10/24/2023. The Plan of Care dated 10/24/2023 (effective 10/24/2023 to 01/21/2024) and the Plan of Care dated 01/22/2024 (effective 01/22/2024 to 03/21/2024) included the Social Worker’s monthly visit frequency. The discipline frequency documented in the Interdisciplinary Group Meetings (IDT) 11/02/2023, 11/13/2024, 11/27/2024, 12/08/2024, 12/22/2024, 01/05/2024, 01/09/2024, 01/30/2024, 02/09/2024, 02/23/2024, 03/01/2024, and 03/15/2024 was for monthly Social Work visits. There were no Social Work visits documented and no missed visits documented. visits Clinical Record 3: The patient elected the hospice benefit on 12/01/2023 with the primary diagnosis of Senile Degeneration of the Brain. The Plan of Care dated 12/01/2023 (effective 12/01/2023 to 02/28/2024) and the Plan of Care dated 02/29/2024 (effective 02/29/2024 to 05/28/2024) included a frequency of once-weekly nursing visits. There was a twenty-one-day gap in Registered Nurse visits from 01/09/2024 to 01/30/2024 and from 03/05/2024 to 03/26/2024. The Licensed Vocational Nurse (LVN) had documented visits on 01/16/2024, 01/23/2024, 03/12/2024, and 03/19/2024. Clinical Record 4: The patient elected the hospice benefit on 09/29/2022 for the primary diagnosis of Acute Respiratory Failure with Hypoxia. The Plan of Care dated 01/22/2024 (effective 01/22/2024 to 03/21/2024) and the Plan of Care dated 03/22/2024 (effective 03/22/2024 to 05/20/2024) included once-weekly nursing visits. There was a sixteen-day gap in Registered Nurse (RN) visits from 12/13/2023 to 12/29/2023. The Licensed Vocational Nurse (LVN) documented a visit on 12/20/2023. There was another sixteen-day gap in RN visits from 03/05/2024 to 03/21/2024. The LVN documented a visit on 03/14/2024. Clinical Record 6: The patient elected the hospice benefit on 12/19/2023 for the primary diagnosis of Protein Calorie Malnutrition. The Plan of Care dated 12/19/2023 (effective 12/19/2023 to 03/17/2024) and the Plan of Care dated 03/18/2024 (effective 03/18/2024 to 06/15/2024) included a frequency of twice-weekly nursing visits. One missed visit was documented for the week of 12/25/2023, but no other nursing visit was documented that week. There was a nineteen-day gap in Registered Nurse visits from 01/04/2024 to 01/23/2024. Licensed Vocational Nurse (LVN) visits were documented on 01/09/2024, 01/12/2024, 01/16/2024, and 01/18/2024. Clinical Record 12: The patient elected the hospice benefit on 09/23/2023. The Plan of Care dated 12/22/2022 (effective 12/22/2023 to 03/20/2024) included orders for the nurse to visit the patient twice weekly. There was a twenty-one-day gap in Registered Nurse visits from 01/16/2024 to 02/06/2024. Licensed Vocational Nurse visits were documented on 01/02/2024, 01/04/2024, 01/09/2024, 01/11/2024, 01/23/2024, 01/25/2024, and 01/30/2024. Clinical Record 14: The patient elected the hospice benefit on 10/03/2023. The Plan of Care dated 10/03/2023 (effective 10/3/2023 to 12/31/2023) and the Plan of Care dated 01/01/2024 (effective 01/01/2024 to 02/29/2024) included an order for the nurse to visit the patient twice a week and the Social Work and Chaplain to see the patient’s once monthly. There was a nineteen-day gap in Registered Nurse (RN) visits from 12/28/2023 to 01/16/2024 and a sixteen-day gap in RN visits from 01/16/2024 to 02/01/2024. Licensed Vocational Nurse visits documented on 01/02/2024, 01/04/2024, 01/09/2024, 01/11/2024, 01/23/2024, 01/25/2024, and 01/30/2024. Social Work visits were documented on 10/19/2023, 11/09/2023, 12/11/2023, and 02/05/2024. There was no January 2024 Special Work visit, and no missed visit was reported. There were Chaplain visits documented on 10/05/2023, 12/14/2023, 01/22/2024, and 02/20/2024. There was no November 2023 visit documented and no missed visit documented. Clinical Record 15: The patient elected the hospice benefit on 06/19/2023 and was discharged from hospice services on 11/28/2023. The Plan of Care dated 06/19/2023 (effective 06/19/2023 to 09/16/2023) included a frequency of nursing visits once a week and for the Social Worker to visit once a month. The Plan of Care dated 09/17/2023 (effective 09/17/2023 to 12/15/2023) continued once-weekly nursing visits from 09/18/2023 to 10/01/2023, then increased to twice a week from 10/02/2023 to 12/15/2023. The frequency of Social Work visits remained once a month. There was a sixteen-day gap in Registered Nurse visits from 10/30/2023 to 11/15/2023. Licensed Vocational Nurse visits were documented on 11/01/2023, 11/06/2023, 11/08/2023, and 11/13/2023. There were Social Work visits documented on 09/16/2023 and 10/11/2023, but no July or August 2023 visits were reported, no missed visits were documented, and no communication notes. Clinical Record 16: The patient elected the hospice benefit on 03/01/2023 and was discharged from hospice service on 05/15/2023. The Plan of Care dated 03/01/2023 (effective 03/01/2023 to 05/29/2023) included a once-weekly nursing visit frequency from 03/03/2023 to 03/05/2023 and then increased to twice-weekly from 03/06/2023 to 05/29/2023. The Social Work frequency was documented at once-monthly visits, and the Chaplain frequency of visits was set at two to three times a month. There was a twenty-day gap in Registered Nurse visits from 03/10/2023 to 03/30/2023. Licensed Vocational Nurse visits were documented 03/16/2023, 03/21/2023, and 03/28/2023. No Social Work visits were documented, no missed visits were noted, and no communication notes or frequency changes were pointed out in the Interdisciplinary Group meetings. There were Chaplain visits documented on 03/05/2023 and 03/15/2023, a visit documented on 05/02/2023, and a missed visit documented for 05/12/2023. There were no Chaplain visits for April 2023, no missed visits documented, no communication notes, and no IDT notes. Clinical Record 18: The patient elected the hospice benefit on 03/25/2023 and died on hospice services on 11/22/2023. The Plan of Care dated 09/21/2023 (effective 09/21/2023 to 11/19/2023) included a once-a-month visit frequency for the Social Worker and the Chaplain. No visits were documented during October 2023 for either the Chaplain or the Social Worker, no missed visit was documented, no communication note, and no note was reported in the Interdisciplinary Group Meetings on 009/28/2023, 10/09/2023, 10/17/2023, or 11/02/2023 regarding a change in the visit frequencies or any missed visits. Clinical Record 19: The patient elected the hospice benefit on 03/21/2022 and died on hospice services on 11/23/2023. The Plan of Care dated 09/22/2023 (effective 09/22/2023 to 11/20/2023) included a once monthly Chaplain visit frequency. There was no Chaplain visit documented for October 2023, no missed visit documented, no communication note (quick note), and no note documented in the Interdisciplinary Group Meetings on 10/04/2023 or 10/20/2023 regarding a change in the Chaplain’s frequency of visits or any missed visits. It was confirmed during joint record reviews and interviews with the Administrator (Staff 1) and the Clinical Director (Staff 2) on 03/19/2024, 03/20/2024, and 03/21/2024 that there were gaps in Registered Nurse visits, missed visits not documented, and/or discipline frequencies not changed as appropriate.”

“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. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that each patient’s Plan of Care was updated with planned interventions based on updated assessment data. The agency policy “Plan of Care” (DOC ID: 3.19.2) with the revised date of 03/22/2022 read in part that ... the IDT reviews and revises the plan of care every two weeks ... to reflect the changing needs of the patient, family, and caregiver... The IDT ... reviews, revises, and documents the individualized plan ... no less frequently than every 15 calendar days. The revised Plan of Care includes information from the patient’s updated comprehensive assessment ...” The hospice policy “Reassessment of the Patient” (DOC ID: 3.28.1) with the revised date of 03/23/2022 included in part that “. The Case Manager and other staff revise the problem list, goals, and interventions and updates the POC after collaboration with the IDG...” Clinical Record 2: The patient elected the hospice benefit on 10/24/2023. During the registered nurse /nurse practitioner (RN/NP) visit documented on 12/20/2023, it was noted that the patient was experiencing malaise, fatigue, a new/increased cough, and wheezing. Further, the NP documented that orders were placed for Levaquin 500mg by mouth daily for five days and a Steroid Dose Pack. The Interdisciplinary Group Meeting on 12/22/2023 included no identified problem or intervention for a respiratory infection. It was confirmed during a joint record review and interview with the Administrator (Staff 1) and the Clinical Director (Staff 2) on 03/21/2024 that the patient’s Plan of Care had not been updated to reflect the treatment of a respiratory infection.”

“It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that each patient’s Plan of Care included measurable outcomes related to the implementation of the Plan of Care. Interdisciplinary Team revised (DOC ID: 3.12.1) 03/22/2022 “ ... The IDT meeting addresses each of the patient’s needs and problems every two weeks or as necessary. These meetings are documented and may include ...developing and modifying the patient/family care plan,... evaluating current services for effectiveness... evaluating patient outcomes and revising goals as needed...... Reviews and updates the Plan of Care for each patient/family receiving hospice care at a minimum of every two weeks ... “ Clinical Record 2: The patient elected the hospice benefit on 10/24/2023. During the registered nurse /nurse practitioner (RN/NP) visit documented on 12/20/2023, it was noted that the patient was experiencing malaise, fatigue, a new/increased cough, and wheezing. Further, the NP documented that orders were placed for Levaquin 500mg by mouth daily for five days and a Steroid Dose Pack. The Interdisciplinary Group Meeting on 12/22/2024 included no goal or measurable outcome related to respiratory infection. Clinical Record 6: The patient elected the hospice benefit on 12/19/2023. The Initial Admission visit documented on 12/19/2023 noted stage 2 wounds to both the right and left iliac crests and the lower back/buttocks. The Plan of Care dated 12/19/2023 (effective 12/19/2023 to 03/17/2024) and 03/18/2024 (effective 03/18/2024 to 06/15/2024) included standard wound care orders for the wounds to be cleansed with normal saline, patted dry, and foam dressing applied at each visit. There were no goals or measurable outcomes defined for the wounds documented in the Plan of Care. It was confirmed during a joint record review and interview with the Administrator (Staff 1) and the Clinical Director (Staff 2) on 03/21/2024 that no goals had been added to the patient’s Plan of Care to reflect progress with the interventions to address the wounds and the infection.”

“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 15 of 19 (79%) clinical records reviewed revealed the agency did not ensure that all members of the Interdisciplinary Group documented review, revision, and update of the patient’s Plan of Care at least every 15 days. The hospice’s policy “Interdisciplinary Team” (DOC ID: 3.12.1) with the revised date of 03/22/2022 included in part that “The IDT involved in the care of the patient consists of ...Registered Nurse/Case Manager, the patient’s attending physician, the Medical Director, Social Worker, Pastoral, Chaplain, or Counselor, Aide/homemaker, Volunteer/Volunteer Coordinator, Bereavement Coordinator/counselor, a pharmacist and nutritionist, therapists: physical, occupational, speech... ... These meetings are documented and may include ...developing and modifying the patient/family care plan, evaluating current services for effectiveness... evaluating patient outcomes and revising goals as needed...The Interdisciplinary Team ... Reviews and updates the Plan of Care for each patient/family receiving hospice care at a minimum of every two weeks ...” The hospice’s policy, “Coordination of Service” (DOC ID: 3.08.1), with the revised date of 03/22/2022, read in part that “.......All professional staff is responsible for developing and modifying the Plan of Care relative to their discipline...” Clinical Record 1: The patient elected the hospice benefit on 08/11/2023. No Chaplain’s signature was on the Interdisciplinary Group Meeting sign-in sheets for 01/12/2024 or 02/09/2024. The 12/15/2023 Interdisciplinary Group Meeting (IDG) sign-in sheet was missing the Chaplain’s signature. The electronic IDG meeting had a Chaplain’s signature dated 01/01/2024, and next to the entry was “Not present.” A chaplain’s note was entered, stating, “Visit with patient monthly. No new concerns noted.” Clinical Record 3: The patient elected the hospice benefit on 12/01/2023. No Chaplain signature was on the Interdisciplinary Group Meeting (IDG) sign-in sheet on 12/15/2023. The electronic IDG meeting did not have the Chaplain’s electronic signature and no note from the Chaplain. The IDG sign-in sheets for 01/12/2024 and 02/09/2024 did not include the Chaplain’s signature. The electronic IDG meetings 01/12/2024 and 02/09/2024 did not contain the Chaplain’s electronic signature. A note on both IDG stated “refused Chaplain services.” Clinical Record 4: The patient elected the hospice benefit on 09/29/2022. The Interdisciplinary Group Meeting (IDG) sign-in sheet for 12/22/2023 did not include the chaplain’s signature. The electronic IDG meeting also did not include the Chaplain’s electronic signature, and it was documented that the Chaplain was “Not present.” A note was included that the patient/family “refused Chaplain services. The IDG sign-in sheets for 01/05/2024 did not have the Social Worker’s signature. The electronic IDG and a Social Work signature dated 01/04/2024 documented that the Social Worker was “Not present.” A note indicated, “family is aware of MSW services are available if psycho/social concerns arise.” The IDG for 01/19/2024 did not include the Social Worker’s signature on the sign-in sheet. On the electronic IDG, the Social Worker signed on 01/20/2024 but stated: “Not present.” A note was included that read, “Patient remains DNR status. MSW assessment is pending. Clinical Record 5: The patient elected the hospice benefit on 08/30/2021. The Interdisciplinary Group Meeting (IDG) sign-in sheet for 12/15/2023 did not include the Chaplain’s signature. The electronic IDG did not include the chaplain’s electronic signature, and there was no note from the chaplain. No Chaplain’s signature was on the Interdisciplinary Group Meeting sign-in sheets for 01/12/2024. The electronic IDG did not have the Chaplain’s electronic signature. It was noted that the Chaplain was “Not present,” with a note that stated, “family refused Chaplain services. There was no Chaplain’s signature on the IDG sign-in sheet for 02/09/2024. The electronic IDG did not include the chaplain’s electronic signature, and there was no note from the chaplain. Clinical Record 6: The patient elected the hospice benefit on 12/19/2023. There was no Chaplain signature on the Interdisciplinary Group Meeting (IDG) sign-in sheets for 01/12/2024 and 02/09/2024. The electronic IDGs did not include an electronic signature from the Chaplain. Read the Chaplain was “Not present.” It was noted that “pt refused Chaplain services.” Clinical Record 7: The patient elected the hospice benefit on 12/29/2023. The sign-in sheet for the 01/12/2024 Interdisciplinary Group Meeting (IDG) meeting did not have the Chaplain’s signature. The electronic IDG meeting did not have the Chaplain’s electronic signature. A note from the chaplain was documented. The sign-in sheet for the IDG 01/26/2024 did not have the Chaplain’s signature. The electronic IDG did not have an electronic signature from the Chaplain. A note indicated “no new spiritual concerns.” No Social Worker or Chaplain was included on the sign-in sheet for the IDG dated 02/23/2024. There was no electronic signature from the Social Worker or Chaplain, and it was indicated “Not present” next to their names. Clinical Record 8: The patient elected the hospice benefit on 02/29/2024. The Social Worker’s signature was missing from the Interdisciplinary Group Meeting (IDG) sign-in sheet for 03/01/2024. The electronic IDT did not have an electronic Social Worker signature. It was documented that the Social Worker was “Not present.” A note was documented: “MSW visit pending; will reach out to schedule a time.” The IDG 03/15/2024 sign-in sheet was missing the social worker’s and chaplain’s signatures. There were no electronic signatures on the electronic IDG from the Social Worker or Chaplain, and both said: “Not present.” It was noted on both that “refused services.” Clinical Record 11: The patient elected the hospice benefit on 04/11/2023. The Interdisciplinary Group Meeting (IDG) 12/15/2023 sign-in sheet did not include signatures from the Chaplain or the Social Worker. On the electronic IDG, the Social Worker’s signature was dated 12/27/2023, noted the Social Worker was “Not present” but did include a Social Work note. The Chaplain’s electronic signature dated 01/01/2024 was also noted as “Not present” and included a note from the Chaplain. On 01/12/2024, the sign-in sheet did not include the social worker’s or chaplain’s signature. The electronic IDG included a Social Worker’s signature dated 01/09/2024, a note the Social Worker was “Not present,” and a note from the Social Worker. The chaplain’s electronic signature was dated 01/26/2023. It was noted that the chaplain was “Not present,” and a note from the chaplain was included. The IDG sign-in sheet for 02/09/2024 did not include the Social Worker or Chaplain’s signature. The Social Worker electronically signed on 02/08/2024 but was noted as “Not present,” but there was a Social Worker note. There was no electronic signature or note from the Chaplain. Clinical Record 12: The patient elected the hospice benefit on 09/23/2023. The Interdisciplinary Group Meeting (IDG) on 12/15/2023 did not include the Social Worker or Chaplain’s signature on the sign-in sheet. The electronic IDG included an electronic signature from the Social Worker dated 12/27/2023 and a Social Worker note documenting that she was “Not present.” The Chaplain electronically signed on 01/01/2024 included a note but noted that he was “Not present.” The IDG sign-in sheet for 01/12/2024 did not include the social worker’s or chaplain’s signature. The electronic IDG included a Social Worker signature dated 01/09/2024, “Not present,” but did include a note. There was no electronic signature from the Chaplain; there was a note, but it was documented that he was “Not present.” The IDG sign-in sheet did not include the social worker’s or chaplain’s signature. The Social Worker electronically signed on 02/08/2024, showed “Not present,” and included a Social worker’s note. There was no Chaplain electronic signature or note, and it read that he was “Not present.” There was no Social Worker’s signature on the sign-in sheet for 02/23/2024. The electronic IDG did not include any Social Worker note or electronic signature. Clinical Record 13: The patient elected the hospice benefit on 01/18/2024. The Interdisciplinary Group Meeting (IDG) 02/09/2024 sign-in sheet did not include the Social Worker or Chaplain’s signature. The Social Worker electronically signed 02/08’/2024 but noted as “Not present.” There was a Social Work note. There was no electronic signature or note from the chaplain. It was stated the Chaplain was “Not present.” Clinical Record 14: The patient elected the hospice benefit on 10/03/2023. The Interdisciplinary Group Meeting (IDG) 12/08/2023 sign-in sheet did not include the Social Worker’s signature. There was a Social Worker note but no electronic signature from the Social Worker, and it was noted that she was “Not present.” The sign-in sheet for the IDG for 12/22/2023 did not include the Chaplain or Social Worker’s signature. The electronic IDG did not include the Chaplain or Social Worker’s electronic signature; both were noted as “Not present.” There were Social Worker and Chaplain notes. The sign-in for the IDG dated 01/30/2024 did not include the Chaplain’s signature. There was a Chaplain note but it was noted that he was “Not present,” and there was not a Chaplain’s electronic signature. Clinical Record 15: The patient elected the hospice benefit on 06/19/2023 and was discharged from hospice services on 11/28/2023. The Interdisciplinary Group Meeting 08/11/2023 sign-in sheet contained no Chaplain or Social Worker signatures. The electronic IDG did not include any notes from the Social Worker or Chaplain. There was no electronic Social Worker signature, and the Chaplain electronically signed on 12/13/2023. The IDG sign-in sheet for 10/20/2023 did not include the Chaplain’s signature. The electronic IDG meeting noted that the Chaplain was “Not present,” and the Chaplain’s electronic signature was dated 10/31/2023. Clinical Record 16: The patient elected the hospice benefit on 03/01/2023 and was discharged from hospice services on 05/15/2023. The Interdisciplinary Group Meeting (IDG) sign-in sheet dated 03/24/2023 did not include the Social Worker’s signature. The electronic IDG included an electronic s; signature from the Social Worker dated 03/26/2023 but no note. The IDG sign-in sheet for the meeting dated 04/21/2023 did not include the Social Worker’s signature. The electronic IDG included a note from the Social Worker, but the electronic signature was dated 04/25/2023. The IDG sign-in sheet for the meeting dated 05/05/2023 did not include the Social Worker’s signature. The electronic IDG included no Social Work note; the electronic signature was dated 05/08/2023. Clinical Record 18: The patient elected the hospice benefit on 03/25/2023 and died on hospice services on 11/22/2023. The Interdisciplinary Group Meeting (IDG) sign-in sheet dated 08/04/2023 did not contain the Social Worker’s signature. The electronic IDG did not include any note or electronic signature from the Social Worker. The IDG 09/01/2023 included no Chaplain or Social Worker’s signature. The electronic IDG did not include a Chaplain or Social Worker’s electronic signature or any Chaplain or Social Worker’s note. The IDG for 09/15/2023 did not include a signature from the Social Worker on the sign-in sheet or electronic IDG. There was no Social Work note included. The sign-in sheet for the IDG dated 09/28/2023 did not include the Chaplain’s signature. There was an electronic signature from the Chaplain, but it was dated 10/04/2023. The IDG sign-in sheet for 10/09/2023 did not include the signature of the Chaplain. The Chaplain’s electronically signed on 10/12/2023. The IDG sign-in sheet for 10/20/2023 did not include the Social Worker’s signature. The electronic IDG did not include any note or electronic Social Worker signature. Clinical Record 19: The patient elected the hospice benefit on 03/21/2022 and died on hospice services on 11/23/2023. The sign-in sheet for the Interdisciplinary Group Meeting (IDG) on 08/25/2023 did not include a Social Worker’s signature. The electronic IDG did not include a Social Worker’s electronic signature or note. The IDG for 09/08/2023 did not include the Social Worker’s signature. The electronic IDG did not include a Social Worker’s electronic signature or note. The IDG 10/202023 sign-in sheet did not include the Chaplain’s signature. The electronic IDG included an electronic signature from the Chaplain dated 10/31/2023 and noted that he was “Not present.” A Chaplain note was included. The IDG 11/17/2023 sign-in sheet did not include the Chaplain’s signature. The electronic IDG noted the Chaplain was “Not present.” There was no electronic signature, but there was a note that was documented. The Social Worker’s signature was dated 11/29/2023. During joint record review and interviews with the Administrator (Staff 1) and the Clinical Director on 03/20/2024 and 03/21/2024, it was confirmed that there were issues with how comfortable the team was in using the Electronic Medical Record for documenting the Interdisciplinary Group Meetings and that before approximately October 2023, the documentation was done strictly on paper forms. Both the Administrator and the Clinical Director observed the absence of some signatures from the sign-in sheets and/or the electronic IDG documentation.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency did not ensure that that the Hospice Registered Nurse documented supervision of the Hospice Aide every 14 days. The agency policy “Aide Supervisory Visits” (DOC ID: 3.52.1) with the revised date of 03/23/2022 read in part that “... A supervisor visit will be performed by an RN every 14 days ... in order to evaluate the quality and appropriateness of care provided ...) Clinical Record 12: The patient elected the hospice benefit on 09/23/2023. The plan of Care dated 12/22/2023 (effective 12/22/2023 to 03/20/2024) included orders for the Hospice Aide to visit the patient three times a week beginning 12/25/2023. There were Hospice Aide visits 01/15/2024, 01/19/2024, 01/22/2024, 01/26/2024, 01/29/2024, 02/02/2024, and 02/05/2024. There was a twenty-one-day gap between the RN visits on 01/16/2024 and 02/06/2024; thus, no Hospice Aide supervision was performed in the fourteen-day required time. Clinical Record 14: The patient elected the hospice benefit on 10/03/2023. The Plan of Care dated 10/3/2023 (effective 10/03/2023 to 12/31/2023 included an order for a Hospice Aide visit to be done twice a week beginning 10/09/2023. The Plan of Care dated 01/01/2024 (effective 01/01/2024 to 02/29/2024) included orders for the Aide to visit the patient twice weekly. There were Hospice Aide visits 12/28/2023, 01/04/2024, 01/09/2024, 01/16/2024, 01/18/2024, 01/23/2024, 01/25/2024, 01/30/2024, and 02/01/2024. There was a nineteen-day gap in RN visits from 12/28/2023 to 01/16/2024 - thus a gap in Hospice Aide supervision. There was another RN gap in visits from 01/16/2024 to 02/0/2024, thus outside the fourteen-day requirement. During a joint record review and interviews with the Administrator (Staff 1) and the Clinical Director (Staff 2) on 03/28/2024 and 03/29/2024 confirmed that there were gaps in Registered Nurse visits and thus, gaps in supervision of the Hospice Aide.”

“It is required that a patient’s 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 signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 19 (21%) clinical records reviewed revealed the agency did not ensure that the Hospice Election Statement was signed by the patient/representative prior to the hospice start of care date. The hospice’s policy “Election of Benefit” (DOC ID: 3.03.2) with a revised date of 03/22/2022 included in part that “...The Medicare/Medicaid beneficiary must complete the Election Statement before the Hospice Medicare Benefit (HMB) may begin. The Election Statement must be signed no later than the first day of hospice services...” Clinical Record 4: The patient elected the hospice benefit on 09/29/2023, and the hospice care began with a Registered Nurse visit the same day. The paper document entitled Hospice Election of Medicare Benefit form with an effective start of care date of 09/29/2023 was signed by the patient’s representative on 9/30/2023, the day after the start of care. Clinical Record 14: The patient elected the hospice benefit on 10/3/2023, and the hospice care began with a Registered Nurse visit the same day. The electronic document Hospice Election of Medicare Benefit form with an effective date of 10/03/2023 was signed by the patient/representative on 10/04/2024, the day after the start of care. Clinical Record 16: The patient elected the hospice benefit on 03/01/2023, and the hospice care began with a Registered Nurse visit the same day. The electronic document Hospice Election of Medicare Benefit form with an effective start of care date of 03/01/2023 was signed by the patient on 03/05/2023, four days after the start of care. Clinical Record 18: The patient elected the hospice benefit on 03/25/2023, and the hospice care began with a Registered Nurse visit the same day. The electronic document Hospice Election of Medicare Benefit form with an effective start of care date of 03/25/2023 was signed by the patient’s representative on 03/26/2023, the day after the start of care. It was confirmed during an interview and joint clinical record review with the Administrator (Staff 1) on 03/28/2024 that the date that shows on the Hospice Election of Medicare Benefits form is not the same day or before the patient started hospice services. During a discussion with the Administrator and joint record review, she observed that the date of the electronic document was documented as the date the nurse documented and signed the admission visit. There was no separate verification of the date the patient/representative signed the Hospice Election form.”