Society Hospice & Palliative Care, Inc.

“It is required that 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. The IDG members provide the care and services offered by the organization. THIS IS A CONTINUING CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure the patients were provided coordination of care, continuous assessments of patient’s and family’s needs, and that the interdisciplinary plan of care was implemented {HCPC.19. I/L540}; Failed to ensure the Interdisciplinary Group, in collaboration with the individual’s attending, reviewed, revised, and documented the patient’s individualized care plan as frequently as the patient’s condition required but no less frequently than every 15 calendar days {HCPC.22. I/L552}; Failed to ensure the Interdisciplinary Group, in its entirety, supervised the care and services provided to the patient and family {HCPC.1. I/L539}; and Failed to ensure the interdisciplinary plan of care was implemented {HCPC. 19. I/L543}; and Failed to ensure that each patient’s individualized written plan of care identified planned interventions based on problems identified in the initial comprehensive assessments {HCPC.21. I/L545}. 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 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 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. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the agency did not ensure the IDG, in its entirety, documented the supervision of the care and services provided to the patient and family. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 1: The patient elected hospice services on 3/4/2024. A review of the clinical record identified the two (2) “Order Plan of Care” forms dated 3/4/2024, and one (1) “Plan of Care” form dated 3/11/2024, which all included the same content to include medications, visit frequencies, and plan of care problems, goals and/or interventions. During an interview on 4/26/2024, the administrator confirmed the “Plan of Care” form dated 3/11/2024 was not on a scheduled IDG meeting date. During the dates of service reviewed 3/16/2024 through 3/26/2024, there were no documented Interdisciplinary Group (IDG) meetings in the clinical record for the scheduled IDG meetings on 3/22/2024, 4/5/2024, and 4/19/2024. During the joint clinical record review and interviews on 4/25/2024, the administrator/social worker, RN Supervisor, and Alternate RN Supervisor confirmed the missing documented IDG meetings. Clinical Record 2: The patient elected hospice services on 3/4/2024. A review of the clinical record identified the three (3) “Order Plan of Care” forms dated 3/4/2024 which all included the same content including medications, visit frequencies, and plan of care problems, goals, and/or interventions. During the dates of service reviewed 3/16/2024 through 3/26/2024, there were no documented Interdisciplinary Group (IDG) meetings in the clinical record for the scheduled IDG meetings on 3/22/2024, 4/5/2024, and 4/19/2024. During the joint clinical record review and interviews on 4/25/2024, the administrator/social worker, RN Supervisor, and Alternate RN Supervisor confirmed the missing documented IDG meetings. During interviews on 4/25/2024, the Medical Director, Chaplain/Bereavement Coordinator, RN Supervisor (who is also the visiting nurse), and the Social Worker validated that IDG meetings are completed by Zoom every other Friday. During an interview on 4/25/2024, the Administrator stated, “We do not have documented IDG meetings to show the review of the plan of care and do not have IDG meeting attendance records”. Additionally, the RN Supervisor nurse stated on 4/25/2024, “I am typing in a nursing summary for the IDG, and I do not know why it is not saved in the clinical record”, “I do not know how to update the incorrect visit frequencies in the orders and/or plan of care or how to add interventions to the plan of care”, and “I am new and need training in this (EMR system)”. Additionally, during the clinical record review and interviews on 4/25/2024, the RN Supervisor, Alternate RN Supervisor, and Administrator/IDG Social Worker confirmed the missing documented IDG meetings in the clinical record. There was no evidence the agency’s corrective action plan was implemented. The actions the agency included to correct the deficiency cited included, “ The Director of Nursing (DON) will oversee the timely acquisition of physician signatures on care plan reviews, revisions, and related documents, ensuring that these occur bi-weekly or during IDT meetings as necessary to reflect changes in patient status’, “A checklist specifically designed for post- IDT/IDG meetings has been implemented to ensure prompt documentation”, “Leveraging this Post IDT/IDG Checklist, the DON has instituted a bi-weekly review of all patient charts to systematically identify and address any instances of non-compliance with established procedures”. There was no evidence of the IDG meeting plan of care reviews, either bi-weekly or during IDG meetings, no evidence a checklist specifically designed for post-IDT/IDG meetings had been implemented to ensure prompt documentation, and no evidence bi-weekly reviews of the patient charts had been completed. During an interview on 4/25/2024, the RN Supervisor Nurse stated, “I am new and still need training in this (EMR system)”. Additionally, during an interview on 4/26/2024, the Administrator confirmed the missing clinical record review audits, the missing IDT/IDG Checklist, and missing evidence of bi-weekly or during IDG meeting reviews. THIS IS A CONTINUED REQUIRED ACTION. During interviews on 4/25/2024, the Medical Director, Chaplain/Bereavement Coordinator, RN Supervisor (who is also the visiting nurse), and the Social Worker validated that IDG meetings are completed by Zoom every other Friday. During an interview on 4/25/2024, the Administrator stated, “We do not have documented IDG meetings to show the review of the plan of care and do not have IDG meeting attendance records”. Additionally, the RN Supervisor nurse stated on 4/25/2024, “I am typing in a nursing summary for the IDG and I do not know why it is not saved in the clinical record”, “I do not know how to update the incorrect visit frequencies in the orders and/or plan of care or how to add interventions to the plan of care”, and “I am new and need training in this (EMR system)”. Additionally, during the clinical record review and interviews on 4/25/2024, the RN Supervisor, Alternate RN Supervisor, and Administrator/IDG Social Worker confirmed the missing documented IDG meetings in the clinical record. There was no evidence the agency’s corrective action plan was implemented. The actions the agency included to correct the deficiency cited included, “ The Director of Nursing (DON) will oversee the timely acquisition of physician signatures on care plan reviews, revisions, and related documents, ensuring that these occur bi-weekly or during IDT meetings as necessary to reflect changes in patient status’, “A checklist specifically designed for post- IDT/IDG meetings has been implemented to ensure prompt documentation”, “Leveraging this Post IDT/IDG Checklist, the DON has instituted a bi-weekly review of all patient charts to systematically identify and address any instances of non-compliance with established procedures”. There was no evidence of the IDG meeting plan of care reviews, either bi-weekly or during IDG meetings, no evidence a checklist specifically designed for post-IDT/IDG meetings had been implemented to ensure prompt documentation, and no evidence bi-weekly reviews of the patient charts had been completed. During an interview on 4/25/2024, the RN Supervisor Nurse stated, “I am new and still need training in this (EMR system)”. Additionally, during an interview on 4/26/2024, the Administrator confirmed the missing clinical record review audits, the missing IDT/IDG Checklist, and missing evidence of bi-weekly or during IDG meeting reviews.”

“It is required that the hospice must designate a registered nurse that is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the hospice did not ensure the interdisciplinary plan of care was implemented. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 1: The patient elected hospice services on 3/4/2024. A review of the clinical record identified two (2) “Order Plans of Care” forms dated 3/4/2024 and the “Plan of Care” dated 3/11/2024 which all included physician visits at one time a month, and hospice aide visits at three times a week. A review of the clinical record identified a missing physician visit note for March 2024 and missing aide visit notes during the dates of review 3/16/24-4/25/24. There were no documented IDG conferences, physician’s orders, and/or plan of care revisions to update the visit frequency order on the Order Plan of Care. There was no documentation in the clinical record to explain the missed physician and/or hospice aide visits. During an interview on 4/25/2024, the RN Supervisor Nurse who admitted the patient and completed the Orders Plan of Care on 3/4/2024 stated, “The order for the physician visit one time a month is a mistaken entry, and the hospice aide three times a week is no longer correct”. “I added the aide visits on the date of admission, then at my next visit, the patient no longer wanted the aide visits, and I did not discontinue the aide visits”, and “I am new to this electronic medical record system, and I need more training”. Additionally, during an interview on 4/25/2024, the Administrator/IDG Social Worker stated, “The physician does not see the patient one time a month”. During joint clinical record review and interviews on 4/25/2024, the RN Supervisor Nurse, Alternate RN Supervisor Nurse, and Social Worker/Administrator confirmed the missing physician and hospice aide visit notes, as included on the Order Plan of Care. Clinical Record 2: The patient elected hospice services on 3/4/2024. A review of the clinical record identified three (3) “Order Plans of Care” forms dated 3/4/2024 which all included physician visit frequency of one time a month and social worker visit frequency of one time a week. During the dates of service reviewed, there was one missing physician visit note for March 2024, and one social worker visit missing for the weeks of 3/18/2024, 3/25/2024, 4/1/2024, 4/8/2024, and 4/18/2024. There were no documented IDG conferences, plan of care revisions, missed visit documentation, and/or physician’s orders to change or justify why the visit frequency order on the Order Plan of Care was not completed for the physician and social worker missing visits. During joint clinical record review and interviews on 4/25/2024, the Administrator/IDG Social Worker, RN Supervisor Nurse, and the RN Alternate Supervisor Nurse confirmed the missing documented IDG conferences, physician orders, and/or plan of care revisions to update the visit frequencies, and confirmed the missing physician, social worker, and hospice aide visit notes. There was no evidence the agency’s corrective action plan was implemented. The actions the agency included to correct the deficiency cited included, “The DON will conduct regular reviews of established tools on a weekly basis meticulously analyzing data to identify any emerging patterns of compliance or non-compliance”. During an interview on 4/26/2024, the Administrator confirmed the consultant completed the initial in-service with staff on 4/5/2024 and that there are no audits completed. During an interview on 4/25/2024, the RN Supervisor who admitted the patient and completed the Order Plan of Care dated 3/4/2024 stated, “The physician visit frequency of one time a month and the social worker visit frequency of one time a week are mistaken entries”, and “I am new to (name of EMR) and need more training”. During joint clinical record review and interviews on 4/25/2024, the RN Supervisor Nurse, Alternate RN Supervisor Nurse, and Social Worker/Administrator confirmed the missing physician, hospice aide, and social worker visit notes. During an interview on 4/25/2024, the Social Worker stated, “I am only seeing the patient one time a month”.”

“It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the hospice did not ensure the interdisciplinary plan of care was implemented. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 1: The patient elected hospice services on 3/4/2024. A review of the clinical record identified two (2) “Order Plans of Care” forms dated 3/4/2024 and the “Plan of Care” dated 3/11/2024 which all included physician visits at one time a month, and hospice aide visits at three times a week. A review of the clinical record identified a missing physician visit note for March 2024 and missing aide visit notes during the dates of review 3/16/24-4/25/24. There were no documented IDG conferences, physician’s orders, and/or plan of care revisions to update the visit frequency order on the Order Plan of Care. There was no documentation in the clinical record to explain the missed physician and/or hospice aide visits. During an interview on 4/25/2024, the RN Supervisor Nurse who admitted the patient and completed the Orders Plan of Care on 3/4/2024 stated, “The order for the physician visit one time a month is a mistaken entry, and the hospice aide three times a week is no longer correct”. “I added the aide visits on the date of admission, then at my next visit, the patient no longer wanted the aide visits, and I did not discontinue the aide visits”, and “I am new to this electronic medical record system, and I need more training”. Additionally, during an interview on 4/25/2024, the Administrator/IDG Social Worker stated, “The physician does not see the patient one time a month”. During joint clinical record review and interviews on 4/25/2024, the RN Supervisor Nurse, Alternate RN Supervisor Nurse, and Social Worker/Administrator confirmed the missing physician and hospice aide visit notes, as included on the Order Plan of Care. Clinical Record 2: The patient elected hospice services on 3/4/2024. A review of the clinical record identified three (3) “Order Plans of Care” forms dated 3/4/2024 which all included physician visit frequency of one time a month and social worker visit frequency of one time a week. During the dates of service reviewed, there was one missing physician visit note for March 2024, and one social worker visit missing for the weeks of 3/18/2024, 3/25/2024, 4/1/2024, 4/8/2024, and 4/18/2024. There were no documented IDG conferences, plan of care revisions, missed visit documentation, and/or physician’s orders to change or justify why the visit frequency order on the Order Plan of Care was not completed for the physician and social worker missing visits. During joint clinical record review and interviews on 4/25/2024, the Administrator/IDG Social Worker, RN Supervisor Nurse, and the RN Alternate Supervisor Nurse confirmed the missing documented IDG conferences, physician orders, and/or plan of care revisions to update the visit frequencies, and confirmed the missing physician, social worker, and hospice aide visit notes. There was no evidence the agency’s corrective action plan was implemented. The actions the agency included to correct the deficiency cited included, “The DON will conduct regular reviews of established tools on a weekly basis meticulously analyzing data to identify any emerging patterns of compliance or non-compliance”. During an interview on 4/26/2024, the Administrator confirmed the consultant completed the initial in-service with staff on 4/5/2024 and that there are no audits completed. During an interview on 4/25/2024, the RN Supervisor who admitted the patient and completed the Order Plan of Care dated 3/4/2024 stated, “The physician visit frequency of one time a month and the social worker visit frequency of one time a week are mistaken entries”, and “I am new to (name of EMR) and need more training”. During joint clinical record review and interviews on 4/25/2024, the RN Supervisor Nurse, Alternate RN Supervisor Nurse, and Social Worker/Administrator confirmed the missing physician, hospice aide, and social worker visit notes. During an interview on 4/25/2024, the Social Worker stated, “I am only seeing the patient one time a month”. THIS IS A CONTINUED REQUIRED ACTION. During joint clinical record review and interviews on 4/25/2024, the Administrator/IDG Social Worker, RN Supervisor Nurse, and the RN Alternate Supervisor Nurse confirmed the missing documented IDG conferences, physician orders, and/or plan of care revisions to update the visit frequencies, and confirmed the missing physician, social worker, and hospice aide visit notes. There was no evidence the agency’s corrective action plan was implemented. The actions the agency included to correct the deficiency cited included, “The DON will conduct regular reviews of established tools on a weekly basis meticulously analyzing data to identify any emerging patterns of compliance or non-compliance”. During an interview on 4/26/2024, the Administrator confirmed the consultant completed the initial in-service with staff on 4/5/2024 and that there are no audits completed.”

“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 and interview. In 2 of 2 (100%) clinical records reviewed, the hospice did not ensure that each patient’s individualized written plan of care identified planned interventions based on problems identified in the initial comprehensive assessments. Clinical Record 1: The patient elected hospice services on 3/4/2024. A review of the clinical record identified two (2) “Order Plans of Care” forms dated 3/4/2024 and the “Plan of Care” dated 3/11/2024 which all included care plan problems and goals for “Pain” and “Falls”. The Orders Plan of Care dated 3/4/1024 included Aspirin and Meloxicam for pain, and “DME: hospital bed and wheelchair”. There was no documented nursing plan of care interventions in the clinical record for the identified problems of “Pain” and “Falls” which were included on the initial nursing assessment dated 3/4/2024. Clinical Record 2: The patient elected hospice services on 3/4/2024. A review of the clinical record identified three (3) “Order Plans of Care” forms dated 3/4/2024 which all included care plan problems and goals for “Pain” and “Falls”. The Orders Plan of Care dated 3/4/1024 included Aspirin for pain, and “DME: cane, walker, and wheelchair”. There was no documented nursing plan of care interventions in the clinical record for the identified problems of “Pain” and “Falls” which were included on the initial nursing assessment dated 3/4/2024. During an interview on 4/25/2024, the RN/Supervisor Nurse who admitted the patient and completed the Order Plan of Care dated 3/4/2024, and is visiting the patient, stated, “I am new to this electronic medical record system (EMR) and I entered the Pain and Fall problems and goals, but I do not know how to enter the plan of care interventions in the EMR”. During an interview on 4/25/2024, the RN/Supervisor Nurse who admitted the patient and completed the Order Plan of Care dated 3/4/2024, and is visiting the patient, stated, “I am new to this electronic medical record system (EMR) and I entered the Pain and Fall problems and goals, but I do not know how to enter the plan of care interventions in the EMR”.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group, in collaboration with the individual’s attending, reviewed, revised, and documented the patient’s individualized care plan as frequently as the patient’s condition required but no less frequently than every 15 calendar days. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 1: The patient elected Hospice services on 3/4/2024. During the dates of service reviewed 3/16/2024 through 4/26/2024, there were no documented Interdisciplinary Group (IDG) meetings in the clinical record for the scheduled IDG meetings on 3/22/2024, 4/5/2024 and 4/4/19/2024 and/or documented IDG meeting attendance records. Clinical Record 2: The patient elected Hospice services on 3/4/2024. During the dates of service reviewed 3/16/2024 through 4/26/2024, there were no documented Interdisciplinary Group (IDG) meetings in the clinical record for the scheduled IDG meetings on 3/22/2024, 4/5/2024 and 4/4/19/2024 and/or documented IDG meeting attendance records. During an interview on 4/25/2024, the RN Supervisor Nurse stated, “I am new and still need training in this electronic medical record system)”. Additionally, during an interview on 4/26/2024, the Administrator confirmed the missing clinical record reviews and/or audits, the missing IDT/IDG Checklist, and missing evidence of bi-weekly or during IDG meeting reviews. During interviews on 4/25/2024, the Medical Director, Chaplain/Bereavement Coordinator, RN Supervisor (who is also visiting the patients), and Social Worker validated that IDG meetings are completed by Zoom every other Friday. During an interview on 4/25/2024, the Administrator stated, “We do not have documented IDG meetings and do not have IDG meeting attendance records”. During an interview on 4/25/2024, the RN Supervisor nurse stated, “I am new to this electronic medical record system and need training”. Additionally, during the clinical record review and interviews on 4/25/2024, the RN Supervisor, Alternate RN Supervisor, and Administrator/IDG IDG Social Worker confirmed the missing documented IDG meetings in the clinical record. The administrator stated, “Here is the email that I sent out to the IDG members with a reminder of the IDG meeting date and times to be held every other Friday”. There was no evidence the agency’s corrective action plan was implemented. The actions the agency included to correct the deficiency cited included, “The DON will oversee the timely acquisition of physician signatures on care plan reviews, revisions, and related documents, ensuring that these occur bi-weekly or during IDT meetings as necessary to reflect changes in patient status’, “A checklist specifically designed for post- IDT/IDG meetings has been implemented to ensure prompt documentation”, “Leveraging this Post IDT/IDG Checklist, the DON has instituted a bi-weekly review of all patient charts to systematically identify and address any instances of non-compliance with established procedures”. There was no evidence of the IDG meeting plan of care reviews, either bi-weekly or during IDG meetings, no evidence a “checklist specifically designed for post- IDT/IDG meetings” had been implemented to ensure prompt documentation”, and no evidence bi-weekly reviews of the patient charts had been completed. THIS IS A CONTINUED REQUIRED ACTION. During interviews on 4/25/2024, the Medical Director, Chaplain/Bereavement Coordinator, RN Supervisor (who is also visiting the patients), and Social Worker validated that IDG meetings are completed by Zoom every other Friday. During an interview on 4/25/2024, the Administrator stated, “We do not have documented IDG meetings and do not have IDG meeting attendance records”. During an interview on 4/25/2024, the RN Supervisor nurse stated, “I am new to this electronic medical record system and need training”. Additionally, during the clinical record review and interviews on 4/25/2024, the RN Supervisor, Alternate RN Supervisor, and Administrator/IDG IDG Social Worker confirmed the missing documented IDG meetings in the clinical record. The administrator stated, “Here is the email that I sent out to the IDG members with a reminder of the IDG meeting date and times to be held every other Friday”. There was no evidence the agency’s corrective action plan was implemented. The actions the agency included to correct the deficiency cited included, “The DON will oversee the timely acquisition of physician signatures on care plan reviews, revisions, and related documents, ensuring that these occur bi-weekly or during IDT meetings as necessary to reflect changes in patient status’, “A checklist specifically designed for post- IDT/IDG meetings has been implemented to ensure prompt documentation”, “Leveraging this Post IDT/IDG Checklist, the DON has instituted a bi-weekly review of all patient charts to systematically identify and address any instances of non-compliance with established procedures”. There was no evidence of the IDG meeting plan of care reviews, either bi-weekly or during IDG meetings, no evidence a “checklist specifically designed for post- IDT/IDG meetings” had been implemented to ensure prompt documentation”, and no evidence bi-weekly reviews of the patient charts had been completed. During an interview on 4/25/2024, the RN Supervisor Nurse stated, “I am new and still need training in this electronic medical record system)”. Additionally, during an interview on 4/26/2024, the Administrator confirmed the missing clinical record reviews and/or audits, the missing IDT/IDG Checklist, and missing evidence of bi-weekly or during IDG meeting reviews.”

“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, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, the hospice did not ensure the patient’s record included, at a minimum, signed physician’s orders, as required by agency policy. Policy, “Authorization and Authentication of Medical Record Entries”, revised 030116, HCL/IM.9, included, in part, “Agency staff will verify...that the orders are complete, accurate, signed and dated”. Clinical Record 1: The patient elected hospice services on 3/4/2024. A review of the clinical record revealed two (2) “Orders Plan of Care” forms dated 3/4/2024 that the physician did not sign. The two (2) “Orders Plan of Care” forms dated 3/4/2024 did not include the electronic signature of the nurse who took the verbal orders. Clinical Record 2: The patient elected hospice services on 3/4/2024. A review of the clinical record revealed three (3) “Orders Plan of Care” forms dated 3/4/2024 that the physician did not sign. The three (3) “Orders Plan of Care” forms dated 3/4/2024 did not include the electronic signature of the nurse who took the verbal orders. During joint record review and interviews on 4/25/2024, the RN Supervisor Nurse, the RN Alternate Supervisor Nurse, and the Administrator confirmed the missing physician signatures on the Orders/Plan of Care forms. Additionally, during joint record review and interviews on 4/26/2024, the RN Alternate Supervisor Nurse, and the Administrator confirmed the missing signatures on the “Orders Plan of Care” forms. Policy, “Authorization and Authentication of Medical Record Entries”, revised 030116, HCL/IM.9, included, in part, “Agency staff will verify...that the orders are complete, accurate, signed and dated”. During joint record review and interviews on 4/25/2024, the RN Supervisor Nurse, the RN Alternate Supervisor Nurse, and the Administrator confirmed the missing physician signatures on the Orders/Plan of Care forms. Additionally, during joint record review and interviews on 4/26/2024, the RN Alternate Supervisor Nurse, and the Administrator confirmed the missing medical director signatures on the “Orders Plan of Care” forms.”

“It is required that 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. The IDG members provide the care and services offered by the organization. This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure the Interdisciplinary Group, in its entirety, supervised the care and services provided to the patient and family {HCPC.1. I/L539}; Failed to ensure the patients were provided coordination of care, continuous assessments of patient’s and family’s needs, and that the interdisciplinary plan of care was implemented {HCPC.19. I/L540}; and Failed to ensure the Interdisciplinary Group, in collaboration with the individual’s attending, reviewed, revised, and documented the patient’s individualized care plan as frequently as the patient’s condition required but no less frequently than every 15 calendar days {HCPC.22. 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 Interdisciplinary group, care planning, and 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 organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition was not met as evidenced by review of clinical records and interviews which revealed the hospice failed to organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers, and families necessary for the palliation and management of the terminal illness and related conditions [HSLG 5.I/L648]; and Failed to ensure he patients were provided coordination of care, continuous assessments of patient’s and family’s needs, and that the interdisciplinary plan of care was implemented {HSLG.2. I/L651}. 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 418.100: Organization and administration 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 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. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed revealed that the hospice did not ensure the Interdisciplinary Group, in its entirety, supervised the care and services provided to the patient and family. Clinical Record 3: The last Interdisciplinary Group (IDG) conference documented was dated 01/20/2023. There were no documented IDG conferences after 01/20/2023. The following IDG conferences were missed: 02/03/2023, 02/17/2023, and 03/03/2023. Clinical Record 4: The last Interdisciplinary Group (IDG) conference documented was dated 01/06/2023. There were no documented IDG conferences after 01/06/2023. The following IDG conferences were missed: 01/20/2023, 02/03/2023, 02/17/2023, and 03/03/2023. Clinical Record 5: The last Interdisciplinary Group (IDG) conference documented was dated 12/23/2022. There were no documented IDG conferences after 12/23/2022. The following IDG conferences were missed: 01/06/2023 and 01/20/2023. Clinical Record 6: The last Interdisciplinary Group (IDG) conference documented was dated 01/06/2023. There were no documented IDG conferences after 01/06/2023. The following IDG conference missed was 01/20/2023. Clinical Record 7: The last Interdisciplinary Group (IDG) conference documented was dated 01/20/2023. There were no documented IDG conferences after 01/20/2023. The following IDG conference missed was 02/03/2023. During an interview on 03/14/2024, the Administrator agreed that the Interdisciplinary Group had not met every fifteen days to review and update the patient’s plans of care.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 8 (75%) clinical records reviewed revealed the hospice did not ensure the patients were provided coordination of care, continuous assessments of patient’s and family’s needs, and that the interdisciplinary plan of care was implemented. Clinical Record 3: The plan of care (POC) dated 10/28/2022 included an order for skilled nursing (SN) visits at one time a week, social worker visits at one time a month, hospice aide visits at two times a week, and the chaplain visits at one time a month. During the clinical record review on 03/15/2024, the last documented SN visit was on 02/27/2023, there was no documented evidence for an explanation of the missed. The patient had not had a SN visit for more than fifteen (15) days. Clinical Record 4: The POC dated 10/16/2022 included a frequency order for SN visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. During the clinical record review on 03/15/2024, the last documented SN visit was dated 02/27/2023, there was no documented evidence of missed visits. The patient had not had a SN visit for more than fifteen (15) days. The last documented chaplain visit was dated 12/22/2022. There were missed chaplain visits for January and February 2023. The clinical record did not have documented evidence for an explanation of the missed chaplain visits. Clinical Record 5: The POC dated 10/16/2022 ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. The last documented SN visit was dated 12/19/2022. The next documentation was for a SN missed visit dated 12/26/2022 and a second documented missed visit dated 01/02/2023. During the clinical record review on 03/15/2024, there were no skilled nursing visits documented after 01/02/2023. Clinical Record 6: The POC dated 10/11/2022 ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. During the clinical record review on 03/15/2024, the last documented RN visit was on 01/23/2023, there was no documented evidence of missed visits. Clinical Record 7: The POC dated 12/08/2022 ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. During the clinical record review on 03/15/2024, the last documented RN visit was on 01/27/2023, there was no documented evidence of missed visits. Clinical Record 8: The POC dated 11/26/2022 ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. The last documented chaplain visit was in December 2022. There were missed chaplain visits for January and February 2023. The clinical record did not have documented evidence for an explanation of the missed chaplain visits. During an interview on 03/15/2024, the Administrator agreed that the patients had been discharged once the IDG became aware that no nursing visits had been made for more than fifteen days.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 8 (75%) clinical records reviewed revealed that the hospice agency did not ensure the Interdisciplinary Group, in collaboration with the individual’s attending, reviewed, revised, and documented the patient’s individualized care plan as frequently as the patient’s condition required but no less frequently than every 15 calendar days. Clinical Record 3: The last Interdisciplinary Group (IDG) conference documented was dated 01/20/2023. There were no documented IDG conferences after 01/20/2023. The following IDG conferences were missed: 02/03/2023, 02/17/2023, and 03/03/2023. Clinical Record 4: The last Interdisciplinary Group (IDG) conference documented was dated 01/06/2023. There were no documented IDG conferences after 01/06/2023. The following IDG conferences were missed: 01/20/2023, 02/03/2023, 02/17/2023, and 03/03/2023. Clinical Record 5: The last Interdisciplinary Group (IDG) conference documented was dated 12/23/2022. There were no documented IDG conferences after 12/23/2022. The following IDG conferences were missed: 01/06/2023 and 01/20/2023. Clinical Record 6: The last Interdisciplinary Group (IDG) conference documented was dated 01/06/2023. There were no documented IDG conferences after 01/06/2023. The following IDG conference missed was 01/20/2023. Clinical Record 7: The last Interdisciplinary Group (IDG) conference documented was dated 01/20/2023. There were no documented IDG conferences after 01/20/2023. The following IDG conference missed was 02/03/2023. Clinical Record 8: The last Interdisciplinary Group (IDG) conference documented was dated 01/20/2023. There were no documented IDG conferences after 01/20/2023. The following IDG conferences were missed: 02/03/2023, 02/17/2023, 03/03/2023, 03/17/2023, 03/31/2023, and 04/072023. Document 1: HCL/PC.8, revised. 011509, stated in part the Interdisciplinary Team Conferences will be held during the patient’s hospice care to monitor and evaluate the patient’s progress, at least every fifteen days, or more frequently if warranted by the patient’s condition. During an interview on 03/14/2024, the Administrator agreed that the Interdisciplinary Group had not met every fifteen days to discuss, review, and update the patient’s plan of care if necessary.”

“It is required that the hospice governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s: Overall management and operation and provision of care and services. This standard was not met as evidenced by document review and interview. This standard was not met as evidenced by clinical record review and interview. In 6 of 8 (75%) clinical records reviewed revealed the hospice did not ensure the patients were provided coordination of care, continuous assessments of patient’s and family’s needs, and that the interdisciplinary plan of care was implemented. Clinical Record 3: The plan of care order (POCO) dated 10/28/2022 that was developed by the interdisciplinary group (IDG) ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, hospice aide visits at two times a week, and the chaplain visits at one time a month. The last documented RN visit was on 02/27/2023, there was no documented evidence of missed visits. The patient had not had a registered nurse visit for more than fifteen (15) days. Clinical Record 4: The plan of care order (POCO) dated 10/16/2022 that was developed by the interdisciplinary group (IDG) ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. The last documented registered nurse visit was dated 02/27/2023, there was no documented evidence of missed visits. The patient had not had a registered nurse visit for more than fifteen (15) days. The last documented chaplain visit was dated 12/22/2022. There were missed chaplain visits for January and February 2023. The clinical record did not have documented evidence for an explanation of the missed chaplain visits. Clinical Record 5: The plan of care order (POCO) dated 10/16/2022 that was developed by the interdisciplinary group (IDG) ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. The last documented registered nurse visit was dated 12/19/2022. The next documentation was for a registered nurse missed visit dated 12/26/2022 and a second documented missed visit dated 01/02/2023. There were no skilled nursing visits documented after 01/02/2023. The patient had not had a registered nurse visit for more than fifteen (15) days. Clinical Record 6: The plan of care order (POCO) dated 10/11/2022 that was developed by the interdisciplinary group (IDG) ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. The last documented RN visit was on 01/23/2023, there was no documented evidence of missed visits. The patient had not had a registered nurse visit for more than fifteen (15) days. Clinical Record 7: The plan of care order (POCO) dated 12/08/2022 that was developed by the interdisciplinary group (IDG) ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. The last documented RN visit was on 01/27/2023, there was no documented evidence of missed visits. The patient had not had a registered nurse visit for more than fifteen (15) days. Clinical Record 8: The plan of care order (POCO) dated 11/26/2022 that was developed by the interdisciplinary group (IDG) ordered the following frequencies of skilled nursing visits at one time a week, social worker visits at one time a month, and the chaplain visits at one time a month. The last documented chaplain visit was in December 2022. There were missed chaplain visits for January and February 2023. The clinical record did not have documented evidence for an explanation of the missed chaplain visits. During an interview on 03/15/2024, the Administrator agreed that the patients had been discharged once the IDG became aware that no nursing visits had been made for more than fifteen days. The administrator explained the details surrounding the live discharges. She stated she had a stroke and was out for some months. When she returned and realized the patients had not been seen by a nurse for more than 15 days, she and the medical director at that time decided to discharge the patients.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §4 18.26 (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, document review and interview. In 5 of 5 (100%) clinical records reviewed that were live discharges while on services revealed that the hospice did not ensure that a copy of the hospice discharge summary that included a summary of the patient’s hospice stay, treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that would assist in the post-discharge continuity of care was forwarded to the patient’s community attending physician. Agency policy PE.1 CH, revised 110113, stated in part that if a patient is discharged from the hospice, a copy of the hospice discharge summary is sent to the attending physician and any requested patient records. Clinical Record 3: The election of hospice was 10/02/2022 with a diagnosis of chronic obstructive pulmonary disease. The patient was discharged on 02/28/2023. There was no documented evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 4: The election of hospice was 07/18/2022 with a diagnosis of unspecified diastolic congestive heart failure. The patient was discharged on 02/28/2023. There was no documented evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 5: The election of hospice was 07/18/2022 with a diagnosis of Chronic Combined Systolic and Diastolic Congestive Heart Failure. The patient was discharged on 01/10/2023. There was no documented evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 6: The election of hospice was 07/19/2022 with a diagnosis of Alzheimer’s Disease Unspecified. The patient was discharged on 01/30/2023. There was no documented evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 7: The election of hospice was 06/11/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease. The patient was discharged on 02/01/2023. There was no documented evidence that a discharge summary was completed and forwarded to the attending physician. The Administrator on 03/15/2024 agreed that a discharge summary had not been completed or sent to the patient’s physician upon discharge.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or the receiving facility or the attending physician requests that. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed for patients that were live discharges while on services revealed that the hospice did not ensure that a copy of the hospice discharge summary that included a summary of the patient’s hospice stay, treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that would assist in the post-discharge continuity of care was forwarded to the patient’s community attending physician. Clinical Record 3: The patient was discharged on 02/28/2023. There was no documented evidence that the discharge summary was completed and did not include .......and forwarded to the patient’s community attending physician. A live discharge note was documented by the social worker on 02/28/2023. Clinical Record 4: The patient was discharged on 02/28/2023. There was no documented evidence that the discharge summary was completed and forwarded to the patient’s community attending physician. A live discharge note was documented by the social worker on 02/28/2023. Clinical Record 5: The patient was discharged on 01/10/2023. There was no documented evidence that the discharge summary was completed and forwarded to the patient’s community attending physician. A live discharge note was documented by the social worker on 01/10/2023. Clinical Record 6: The patient was discharged on 01/30/2023. There was no documented evidence that the discharge summary was completed and forwarded to the patient’s community-attending physician. A live discharge note was documented by the social worker on 01/30/2023. Clinical Record 7: The patient was discharged on 02/01/2023. There was no documented evidence that the discharge summary was completed and forwarded to the patient’s community attending physician. A live discharge note was documented by the social worker on 02/01/2023. The Administrator on 03/15/2024 agreed that a discharge summary was not completed or sent to the patient’s attending upon discharge.”