Cardinal Hospice LLC

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) contract reviewed revealed the agency did not ensure that background checks are completed on contracted employees. REOCCURING REQUIRED ACTION. Contract 1: GIP/RESPITE Contract agreement signed on 02/21/2024. No documented evidence of background checks for their employees up to review date 06/17/2024. In an interview with the Administrator/DON ON 06/17/2024 she confirmed that the contract did not include that criminal background checks are completed on contracted employees. No further information was provided. REOCCURING REQUIRED ACTION.”

“It is required that the hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. It is required that the hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of administrative documents, and interviews with leadership revealed the hospice: Failed to use volunteers in a day-to-day administrative and/or direct patient care role {HCDT.21. I/L644}; Failed to ensure that volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff {HSLG.7. I/L647}; and Failed to provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff {HSLG.7. I/L646}; and Failed to ensure the hospice demonstrated viable and ongoing efforts to recruit and retain volunteers {HSRM.30. I/L645}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the 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 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that an initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 01/08/2024 with a diagnosis of Chronic obstructive pulmonary disease. The initial plan of care dated 01/08/2024 included an order for social work visit 1 time for initial evaluation. There was no documented evidence that the social worker made a visit to the patient. There was no documented evidence of an explanation for the missed visit. Clinical Record 5: The patient elected the hospice benefit on 10/31/2023 with a diagnosis of chronic obstructive pulmonary disease. The initial plan of care 10/31/2023 included an order for the social worker to make an initial visit on 11/03/2023. There was no documented evidence that the social worker made a visit to the patient. There was no documented evidence of an explanation for the missed visit. Clinical Record 6: The patient elected the hospice benefit on 12/08/2023 with a diagnosis of unspecified severe protein calorie malnutrition. The initial plan of care had an order for the social worker to 1 time for 1 week effective 12/11/2023 - 12/16/2023. The social worker made a phone call to the patient on 12/02/2023 in which there was no answer. There was no documented evidence that the social worker followed up or made an initial visit in the first 5 days of hospice care. In an interview and joint clinical record review with the director of nursing she confirmed and agreed that the initial assessment by the social worker was not made in the required 5-day timeframe. She stated that the social worker just recently came on full time. While she was part-time, they had difficulty getting these visits completed.”

“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 and interview. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that an initial bereavement risk assessment was completed. Clinical Record 4: The patient elected the hospice benefit on 04/06/2024 with a diagnosis of Senile degeneration of the brain. There was no documented evidence that an initial bereavement risk assessment was completed by any member of the interdisciplinary team. Clinical Record 10: The patient elected the hospice benefit on 12/21/2023 there was no documented evidence that an initial bereavement risk assessment was completed by any member of the interdisciplinary team. In an interview and joint review of the clinical record with the director of nursing she confirmed that there was no initial bereavement risk assessment completed by the interdisciplinary team.”

“The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) bereavement records reviewed it was revealed that the agency did not ensure that there was a bereavement plan of care for bereaved family’s needs. Clinical Record 10: The patient elected the hospice benefit on 12/21/2023 and expired on 1/30/2024. There was no post bereavement risk assessment or bereavement plan of care found in the clinical record. An initial letter was mailed on 01/31/2024 but no other written evidence of follow up bereavement care. In an interview with the Director of Nursing she stated that the agency was between bereavement coordinators, and this was missed in the transition.”

“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, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed that received aide services revealed that the agency did not ensure that the registered nurse made an on-site supervisory patient’s home no less frequently than every 14 to assess the care and services provided by the aide. Clinical Record 2: The patient elected hospice services on 01/08/2024. On admission the family accepted aide services. The first aide visit was made on 01/24/2024, there was no documented evidence of a registered nurse (RN) supervisory visit made before 02/13/2024. This supervisory visit was made on day 20 after the initial aide visit was made. In an interview and joint review of the clinical record with the director of nursing she confirmed that this visit was made outside of the required guidelines.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care, documented in the patient record, including the time spent. This standard was not met as evidenced by document review and interview. A review of the volunteer program revealed the last documented volunteer program was 2023. In an interview with the Director of Nursing she stated that there had been an individual in the volunteer coordinator position who did not perform up to standard. The role and expectations of this position were not fulfilled appropriately. She stated that the previous volunteer coordinator was terminated in March of 2023 and a new volunteer coordinator was recently hired. The current volunteer coordinator is currently in training and the director of nursing confirmed there were no active volunteers. She stated that if a patient or family voiced the need for a volunteer the staff would meet these needs as best as possible. In an interview with the Director of Nursing she stated that there had been an individual in the volunteer coordinator position who did not perform up to standard. The role and expectations of this position were not fulfilled appropriately. She stated that the previous volunteer coordinator was terminated in March of 2023 and a new volunteer coordinator was hired. The current volunteer coordinator is currently in training and the director of nursing confirmed there were no active volunteers. She stated that if a patient or family voiced the need for a volunteer the staff would meet these needs as best as possible.”

“It is required that the hospice document and demonstrate viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The last documented volunteer program was 2023. There were no documents provided to ensure the hospice demonstrated viable and ongoing efforts to recruit and retain volunteers. In an interview with the Director of Nursing she stated that there had been an individual in the volunteer coordinator position who did not perform up to standard. The role and expectations of this position were not fulfilled appropriately. She stated that the previous volunteer coordinator was terminated in March of 2023 and a new volunteer coordinator was recently hired, March 2024.”

“It is required that the hospice The hospice documents the cost savings achieved through volunteers. Documentation includes: 1. The identification of each position that is occupied by a volunteer; 2. The work time spent by volunteers occupying those positions; 3. Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. The last documented volunteer program was 2023. There was no documented evidence of Hospice volunteers providing day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. In an interview with the Director of Nursing she stated that there had been an individual in the volunteer coordinator position who did not perform up to standard. The role and expectations of this position were not fulfilled appropriately. She stated that the previous volunteer coordinator was terminated in March of 2023 and a new volunteer coordinator was recently hired. The DON started with the agency in March 2023, and she stated to her knowledge there has not been an active volunteer program since she has been there. Required documentation of the volunteer program was not provided.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. In an interview with director of nursing and the volunteer coordinator on 05/07/2024 it was revealed that there were no records on the use of volunteers for patient care or administrative services. The current volunteer coordinator started her role in March 2024 and has not completed training for any active volunteers. She did provide a binder with plans for the volunteer program over the next quarter that was reviewed. In an interview with director of nursing and the volunteer coordinator on 05/07/2024 it was revealed that there were no records on the use of volunteers for patient care or administrative services. The current volunteer coordinator started her role in March 2024 and has not completed training for any active volunteers. She did provide a binder with plans for the volunteer program over the next quarter that was reviewed.”

“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 interview and personnel record review. In 1 of 6 (17%) personnel records reviewed revealed that the agency did not ensure that the volunteer coordinator completed appropriate competency assessments. Personnel Record 4: The volunteer coordinator was hired for this position on 03/20/2024. There was no documented evidence in the personnel record that the volunteer coordinator has completed any competencies for the volunteer coordinator role. During an interview with the director of nursing on 05/08/2024 she confirmed that the competencies had not been completed.”

“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, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) of clinical records of patients that was discharged from hospice services revealed that the agency did not ensure that the patient received and signed a Notice of Medicare Non-Coverage form before discharge. Clinical Record 14: The patient was discharged from hospice care on 04/07/2024 as it was determined that the patient was no longer terminally ill after being on hospice services since 06/13/2023. During joint review of the clinical record with the director of nursing and an interview it was revealed there was no Notice of Medicare Non-Coverage form given or signed by the patient or family. The director of nursing confirmed that the form was overlooked.”

“It is required that hospice inpatient care for respite purposes is provided by one of the following a Medicare-certified hospital or a skilled-nursing facility that also meets the standards specified in §418.110(b) (requiring 24-hour nursing care); and §418.110(e) (regarding home-like patient areas). Or A Medicare or Medicaid certified nursing facility that meets §418.110(e) (regarding home-like patient areas). or a Medicare-certified hospice that meets the conditions of participation for providing inpatient care directly as specified in §418.110. This standard was not met as evidenced by document review and interview. During review of the agency contracts there was no documented evidence of a signed contract to show that the agency was able to provide Respite or General inpatient care/services to any of the agency’s patients. In an interview with the director of nursing she stated that they have been trying to get a contract signed since March 2023 without success. She stated to date they have not had any need for respite or GIP. She stated that they normally perform continuous care in the home for symptom management. She stated that no patients had requested respite, and they did not have a plan in the event that one did. There was also no plan in place if symptoms were not able to be managed in the home. During review of the agency contracts there was no signed contract that would prove the agency was able to provide Respite or General inpatient care/services to any of the agency’s patients. In an interview with the director of nursing she stated that they have been trying to get a contract signed since March 2023 without success. She stated to date they have not had any need for respite or GIP. She stated that they normally perform continuous care in the home for symptom management. She stated that no patients had requested respite, and they did not have a plan in the event that one did. There was also no plan in place if symptoms were not able to be managed in the home.”

“It is required that the designated IDG member provides the SNF/NF oIt is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, the most recent hospice plan of care, hospice election form and any advance directives, physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) of clinical records of patients residing in a skilled nursing facility revealed the agency did not ensure the facility had the required documents for the hospice patient. Home Visit 2: The patient elected hospice services on 04/10/2024 with a diagnosis of malignant neoplasm of female breast. She resides in a skilled nursing facility. During the home visit (Home Visit 2) on 05/07/2024 with the hospice aide (Personnel Record 2) and accompanied by the Director of nursing revealed that the facility did not have any required information readily available for the facility staff. The facility did not have a copy of the hospice plan of care, no election form or any advanced directives, no contact information for hospice staff and no physician certification and recertification of the terminal illness. During an interview with the director of nursing she stated that they have placed binders in this facility with required information and the facility loses it.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by interview and personnel record review. In 4 of 6 (67%) personnel records reviewed revealed that the agency did not ensure that criminal background checks were completed of all hospice employees. Personnel Record 2: Certified Nursing Assistant hired on 01/23/2024. There was no documented evidence found in the personnel record that a criminal background check was completed before providing patient care. Personnel Record 3: Medical Director hired on 05/01/2023. There was no documented evidence found in the personnel record that a criminal background check was completed before providing patient care. Personnel Record 4: Social Worker hired on 03/20/2024. There was no documented evidence found in the personnel record that a criminal background check was completed before providing patient care. Personnel Record 5: Licensed vocational nurse hired on 02/21/2024. There was no documented evidence found in the personnel record that a criminal background check was completed before providing patient care. In an interview and joint review of the personnel records with the director of nursing she confirmed that these criminal background checks were missing from the records. She attempted to locate them without success.”