At Home Hospice and Palliative Care LLC.

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) emergency preparedness (EP) plan reviewed revealed that the agency did not ensure that the hospice-based and community-based risk assessment, using an “all-hazards” approach specific geography and population served was documented. Document 3: The agency developed its emergency preparedness plan in 2021 that included strategies to address emergencies identified in the risk assessment performed, the specific needs of patients served by the agency, communication, cooperation, and collaboration with local, State, and Federal agencies regarding evacuation if/when needed, care and services to be provided by the agency during an emergency, continuity of business functions, and key roles for staff and leadership. There was no evidence to support that the plan had been reviewed and updated at least every two (2) years (2023). On 1/25/24 a joint document review and interview were conducted with the Administrator, who confirmed that the EP had not been reviewed and updated since 2021. The Administrator did report and provide documentation of the emergency plan being activated 1/15/24 during extremely cold weather and icy conditions in the agency’s service area.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) emergency preparedness (EP) plan reviewed revealed that the agency did not ensure that the hospice-based and community-based risk assessment specific to the agency’s service area and population served and using an “all-hazards” approach was documented. Document 3: The agency developed its emergency preparedness plan in 2021, and documentation showed the plan was last activated on 1/15/24 due to extremely cold temperatures and icy conditions within the agency’s service area. Documentation of a hospice and community-based risk assessment, with an “all-hazards” approach, for the year 2023, identifying any possible risks in the geographical area or to the agency’s patient population and lending data to update the EP plan, could not be found. On 1/25/24 a joint document review and interview were conducted with the Administrator, who confirmed that the hospice and community-based risk assessment was not documented for 2023.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness (EP) plan, risk assessment, policies and procedures, and communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes, for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by interview and personnel record review. In 7 of 10 (70%) personnel records reviewed revealed that the agency did not ensure Emergency Preparedness (EP) training and documentation of each training, including dates, participants, and content, was provided at least every two (2) years. Personnel Record 1: The Registered Nurse (RN)/Administrator was hired on 8/2/2020 and received initial emergency preparedness training. The personnel record did not contain documentation that the RN/Administrator completed agency-specific EP training at least every 2 years (2022). Personnel Record 2: The hospice aide was hired on 9/28/2020 and received initial emergency preparedness training. The personnel record did not contain documentation that the aide completed agency-specific EP training at least every 2 years (2022). Personnel Record 3: The Medical Social Worker was hired on 10/4/21 and received initial emergency preparedness training. The personnel record did not contain documentation that the MSW completed agency-specific EP training at least every 2 years (2023). Personnel Record 4: The Chaplain/Bereavement Coordinator was hired on 9/28/2020 and received initial emergency preparedness training. The personnel record did not contain documentation that the aide completed agency-specific EP training at least every 2 years (2022). Personnel Record 7: The Medical Director was hired on 9/28/2020 and received initial emergency preparedness training. The personnel record did not contain documentation that the Medical Director completed agency-specific EP training at least every 2 years (2022). Personnel Record 8: The RN/Alternate Administrator was hired on 8/2/2020 and received initial emergency preparedness training. The personnel record did not contain documentation that the RN completed agency-specific EP training at least every 2 years (2022). Personnel Record 9: The Volunteer was hired on 10/1/21 and received initial emergency preparedness training. The personnel record did not contain documentation that the volunteer completed agency-specific EP training at least every 2 years (2023. On 1/25/24 joint record reviews and an interview were conducted with the Administrator, who confirmed that the personnel records did not contain documentation of staff receiving EP training at least every two (2) years.”

“It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s 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 12 (8%) clinical records reviewed revealed that the agency did not ensure that the Registered Nurse completed an initial assessment within 48 hours of the patient electing hospice care. Clinical Record 12: The patient’s representative elected the hospice care benefit on behalf of the patient starting 10/9/23. The initial nursing comprehensive assessment was completed on 10/13/23 (96 hours after the election of hospice care). On 1/25/24 a joint record review and interview were conducted with the Administrator, who confirmed that the initial assessment was not completed within 48 hours of the patient electing hospice care. The Administrator stated that she did not know that the assessment had to be within 48 hours of the date hospice care was elected.”

“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 11 (9%) clinical records reviewed revealed that the agency did not ensure that the Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five (5) calendar days after the patient elected hospice services. Clinical Record 12: The patient’s representative elected the hospice care benefit starting 10/9/23. The initial psychosocial and spiritual assessments were completed on 10/16/23 (7 days after the election of hospice care). On 1/25/24 a joint record review and interview were conducted with the Administrator, who confirmed that the Interdisciplinary Group’s comprehensive assessment was not completed within five (5) calendar days of the patient electing hospice care.”

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes the history of pain and its treatment, both pharmacological and non-pharmacological, the use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, characteristics of the pain, including, location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping), and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that a pain assessment, including history and treatment of pain, use of a standardized pain assessment tool, characteristics of pain, impact of pain on patient’s activities and function, and the patient’s/family’s goals, was included in the comprehensive assessment. Clinical Record 2: The initial nursing assessment completed on 8/28/23 identified pain as a problem within the Hospice Item Set (HIS). A comprehensive pain assessment including history, treatment, appropriate scale, characteristics, impact on the patient, and patient’s/family’s goals associated with pain could not be found within the initial comprehensive nursing assessment. Clinical Record 12: The initial nursing assessment completed on 10/13/23 identified pain as a problem within the Hospice Item Set (HIS). A comprehensive pain assessment including history, treatment, appropriate scale, characteristics, impact on the patient, and patient’s/family’s goals associated with pain could not be found within the initial comprehensive nursing assessment. On 1/25/24 joint record reviews and an interview were conducted with the Administrator, who confirmed that the initial comprehensive nursing assessment did not include a comprehensive pain assessment.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure the plan of care (POC) reflected the patient’s identified problems and associated goals and interventions. Clinical Record 3: The initial physician Certification of Terminal Illness (CTI) documented that the patient had an active Internal Cardiac Defibrillator (ICD). The POC effective, 9/11/23, did not contain any problems, goals, or interventions associated with the ICD. The initial spiritual care assessment (9/11/23) documented identified spiritual needs including adequate coping, anxiety, grieving, guilt, and relationship to God. The plans of care (POCs), effective 9/11/23 to 12/9/23 and 12/10/23 to 3/8/24, did not contain any problems, goals, or interventions associated with the spiritual needs identified. Clinical Record 11: The Nursing assessments identified and documented pressure wounds to the sacral area (10/27/22) and bilateral heels (1/11/24), and the patient was referred to a contracted wound care specialist for care and treatment of the wounds. Documentation from the wound care specialist (12/18/23) stated that the wound care would be provided by the wound care specialist one (1) time per week, and the hospice nurse would provide wound care two (2) times per week. The plan of care orders did not include interventions detailing the frequency of and identifying who would perform the wound care. On 1/25/24 a joint record review and interview were conducted with the Administrator, who confirmed that the patient did have an ICD and that the POC did not contain goals and interventions associated with the ICD (risks, deactivation at end of life, etc.) and the spiritual needs identified in the spiritual assessment. The Administrator also confirmed that the POC did not include the frequency and persons responsible for providing wound care.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed, in which a Licensed Vocational Nurse (LVN) completed visits, revealed that the agency did not ensure LVN supervisory visits were made monthly per agency policy. Document 2: The policy titled, “Licensed Vocational/Practical Nurse Supervision” stated in part, “...The registered nurse will complete an in-home supervisory visit for all clients receiving services provided by a LPN/LVN, at least every month. The LVN does not have to be present during these visits.” Clinical Record 14: A Licensed Vocational Nurse (LVN) supervisory visit was performed by the Registered Nurse (RN) on 11/3/23. The LVN completed visits on 11/19/23, 12/15/23, 12/27/23, and 1/12/24. The clinical record did not contain documentation of LVN supervisory visits completed from 11/3/23 to the date of record review 1/24/24. On 1/25/24 the policy regarding LPN/LVN supervisory visits was reviewed with the Administrator who clarified that “every month” was defined by the agency as a calendar month. On 1/25/24 a joint record review and an interview were conducted with the Administrator, who confirmed that the clinical record did not contain a monthly LVN supervisory visit by the RN since last completed on 11/3/23.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 10 (10%) personnel records reviewed revealed that the agency did not ensure the skills and competencies of all individuals providing patient care were assessed and that the skills, competencies, and in-service training provided were documented annually per agency policy. Document 4: The policy titled, “Competency Assessment” stated in part, “The competence of all organization clinical personnel ... will be assessed...during the annual performance evaluation. Competency assessments will be documented with the name of personnel, topic, date completed, and record of satisfactory performance.” Personnel Record 1: The Registered Nurse/Administrator was hired on 8/3/2020 and documentation of the initial competency evaluation was completed on 9/1/2020. There was no documented evidence of the annual skills assessment, competencies, and in-service trainings for 2021, 2022, and 2023 per agency policy. On 1/25/24 a joint personnel record review and an interview were conducted with the Administrator who confirmed that the record did not contain documentation of completed annual skills assessment, competencies, and in-service training annually, 2021, 2022, and 2023.”

“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. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed revealed that the agency did not ensure that there were physician orders for all hospice care and services provided. Clinical Record 2: The Medical Social Worker (MSW) documented completed telehealth visits on 11/27/23 and 12/27/23. The Chaplain (CH) documented completed visits on 11/27/23 and 12/27/23. There was no documented evidence of physician orders for the MSW and CH. Clinical Record 4: The nursing communication note dated 11/30/23 documented that the patient was transferred to another Medicare-certified hospice agency. There was no documented evidence of physician orders to transfer the patient’s care and services to another hospice. Clinical Record 5: The nursing discharge note dated 10/16/23 documented that the patient was no longer considered terminally ill and was discharged from hospice services on 10/16/23. There was no documented evidence of physician orders for the discharge. Clinical Record 6: The nursing communication note dated 9/22/23 documented that the patient was admitted to a non-contracted hospital and discharged from hospice services on 9/22/23. There was no documented evidence of a physician order for discharge from hospice services. Clinical Record 7: The nursing discharge note dated 8/14/23 documented that the patient was discharged from hospice services after moving out of the agency’s service area on 8/14/23. There was no documented evidence of a physician order for discharge from hospice services. Clinical Record 8: The nursing discharge note dated 7/21/23 documented that the patient revoked the election of hospice services on 7/21/23 to seek aggressive treatment. There was no documented evidence of a physician order for discharge from hospice services. Clinical Record 11: Nursing assessments identified and documented pressure wounds to the sacral area on 10/27/22 and bilateral heels (1/11/24), and the patient was referred to a contracted wound care specialist for care and treatment of the wounds. Documentation from the wound care specialist (12/18/23) stated that the wound care would be provided by the wound care specialist one (1) time per week, and the hospice nurse would provide wound care two (2) times per week. The clinical record did not include wound care orders identifying who would provide the care and the frequency of care. On 1/25/24 joint record reviews and an interview were conducted with the Administrator who confirmed that the medical records identified did not contain orders for MSW and Chaplain visits, transfer and discharge orders, and wound care orders that identified who would provide the wound care and the frequency.”

“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 and interview. In 2 of 2 (100%) clinical records reviewed, in which the patient was transferred to a Medicare/Medicaid certified facility or hospice, revealed that the agency did not ensure a copy of the hospice discharge summary was forwarded to the receiving facility or hospice. Clinical Record 4: The nursing communication note dated 11/30/2023 documented that the patient was transferred to another Medicare-certified hospice agency. The clinical record did not contain documentation that the discharge summary was forwarded to the receiving hospice. Clinical Record 6: The nursing discharge note dated 9/22/2023 documented that the patient was admitted to the hospital for treatment and discharged from hospice services on 9/22/2023. The clinical record did not contain documentation that the discharge summary was forwarded to the receiving hospital. On 1/25/2024 joint record review and an interview were conducted with the Administrator, who confirmed that the clinical records identified did not include documentation that a discharge summary was forwarded to the receiving hospice and hospital.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed, in which the patient revoked the election of hospice care or was discharged from hospice services, revealed that the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient’s attending physician. Clinical Record 4: The nursing communication note dated 11/30/23 documented that the patient was transferred to another Medicare-certified hospice agency. The clinical record did not contain documentation that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 5: The nursing discharge note dated 10/16/23 documented the patient was found to no longer be terminally ill and was discharged from hospice services on 10/16/23. The clinical record did not contain documentation that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 6: The nursing discharge note dated 9/22/23 documented that the patient was admitted to the hospital for treatment and discharged from hospice services on 9/22/23. The clinical record did not contain documentation that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 8: A statement revoking the elected hospice services was signed by the patient on 7/21/23 to seek aggressive treatment. The clinical record did not contain documentation that the discharge summary was forwarded to the patient’s attending physician. On 1/25/24 a joint record review and an interview were conducted with the Administrator, who confirmed that the clinical records identified did not include documentation that discharge summaries were forwarded to the patients’ attending physicians.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, 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 4 of 5 (80%) clinical records reviewed, in which the patient was discharged from hospice care, revealed that the agency did not ensure a discharge summary was created to include a summary of the patient’s hospice stay, current plan of care, latest physician orders, and any other documentation to assist with continuity of care after discharge. Clinical Record 4: The nursing communication noted dated 11/30/23 documented that the patient was transferred to another Medicare-certified hospice agency. The clinical record did not contain a discharge 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. Clinical Record 5: The nursing discharge note dated 10/16/23 documented the patient was found to no longer be terminally ill and was discharged from hospice services on 10/16/23. The clinical record did not contain a discharge 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. Clinical Record 6: The nursing discharge note dated 9/22/23 documented that the patient was admitted to the hospital for treatment and discharged from hospice services on 9/22/23. The clinical record did not contain a discharge 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. Clinical Record 8: A statement revoking the elected hospice services was signed by the patient on 7/21/23 to seek aggressive treatment. The clinical record did not contain 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. On 1/25/24 joint record reviews and an interview was conducted with the Administrator, who confirmed that the identified clinical records did not contain discharge summary information.”