Anchor of Love Hospice

“It is required that short-term inpatient care must be available for pain control, symptom management, and respite purposes, and must be provided in a participating Medicare or Medicaid facility. THIS IS A CONDITON LEVEL DEFICIENCY. This condition was not met as evidenced by a review of document review and interviews which revealed the hospice: Failed to ensure there was a contract for short-term inpatient care available for pain control, symptom management and respite purposes. {HSIC.5. D/L711}. 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 418.108: Short-term inpatient care. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days after the election of hospice. Clinical Record 11: The patient elected hospice on 03/24/2023, an initial nursing assessment was done on 03/24/2023 and the social worker’s initial assessment was requested for the following month per family. The Chaplain’s initial assessment was completed on 03/30/2023, which was 6 days after the date of the election. During an interview with the Administrator on 10/23/2024 she stated that she could not believe they missed that one, stated that she would be doing more education with clinical staff regarding the timeframe for initial assessments.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; and Other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the drug profile was updated with changes in the comprehensive assessment. The agency’s policy titled Administrative Policy Manual, Medication List and Monitoring PC.85 stated in part “ The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate.” and “Medication monitoring will include appropriate data/information to develop an accurate patient medication history and a current, complete medication profile.” Clinical Record 1: A clinical record review for benefit period 08/01/2024 to 10/29/2024 revealed on 10/18/2024 a new order for clotrimazole cream 1% apply a thin layer to affected areas BID x 14 days. The medication was not updated to the medication list. A comprehensive assessment on 10/18/2024 stated that the patient is using oxygen continuously, no Oxygen on the medication list dated 10/22/2024. Clinical Record 2: A clinical record review for the benefit period 08/31/2024 to 10/29/2024 revealed on the comprehensive assessment dated 10/14/2024 that the patient is using oxygen continuously. There was no documented evidence of Oxygen on the medication list dated 10/22/2024. During an interview with the alternate clinical manager on 10/23/2024 she stated she does not know why the medication list was not updated, but that she would provide additional education to her clinical staff.”

“It is required that the hospice must designate a registered nurse member of the IDG 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 evidence by clinical record review and interview, the agency did not ensure that the hospice registered nurse provided coordination of care, the continuous assessments of the patients and family needs and implementation of the plan of care. Clinical Record 1: A clinical record review for benefit period 08/01/2024 to 10/29/2024 revealed on 10/18/2024 a new order for clotrimazole cream 1% apply a thin layer to affected areas BID x 14 days. The medication was not updated to the medication list. A comprehensive assessment on 10/18/2024 stated that the patient is using oxygen continuously, no Oxygen on the medication list dated 10/22/2024. The record lacked documented evidence that the RN provided coordination of care. Clinical Record 2: A clinical record review for the benefit period 08/31/2024 to 10/29/2024 revealed on the comprehensive assessment dated 10/14/2024 that the patient is using oxygen continuously. There was no documented evidence of Oxygen on the medication list dated 10/22/2024. The record lacked documented evidence that the RN provided coordination of care. Clinical Record 13: The patient elected hospice on 08/09/2024. The patient signed a revocation of hospice services on 08/11/2024. The patient was admitted to the hospital as he wanted to seek aggressive treatment. The clinical record contained no evidence of a documented discharge summary, or a discharge summary sent to patient’s attending physician in accordance with agency policy to ensure the coordination of care. Clinical Record 14: The patient elected hospice on 01/12/2024. The patient was transferred to another hospice on 09/03/2024. The clinical record contained no evidence of a documented discharge summary and no documented evidence of a discharge summary being sent to the patient’s attending physician or to the receiving facility to ensure the coordination of care. During an interview with the Administrator on 10/23/2024 regarding the discharge summary, she stated, “I did not realize we needed to have a discharge summary.””

“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, document review and interview. In 1 of 7 (14%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure that hospice aide services were supervised by a registered nurse no less frequently than every 14 days. The agency’s policy titled Administrative Policy Manual; Employee Supervision HR.60 stated in part “A registered nurse (RN) must make an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the Hospice Interdisciplinary Group/Team (IDG/IDT) meet the patient’s need. The hospice aide does not have to be present during this visit. Clinical Record 10: A review of the clinical record for benefit period 07/24/2024 to 10/21/2024 included an order for hospice aide services ordered 5 times per week. The patient received aide services as ordered starting on 07/25/2024. The first aide supervisory visit was completed on 08/12/2024 which is 18 days after the first aide visit. During an interview with the administrator and alternate clinical manager on 10/23/2024 they both stated that they must have missed that one, but they would be auditing for aide supervision more closely.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 9 (11%) clinical records with multiple benefit periods reviewed revealed the agency did not ensure recertification for hospice care benefit was performed by a review of the patient’s clinical information. The agency’s policy titled Administrative Policy Manual, Physician Services PC.20 states in part “The Hospice physician or a Hospice nurse practitioner will have a face-to-face encounter prior to, but no more than 30 days before the third benefit period, and every benefit period thereafter, to gather clinical findings to determine continued eligibility for hospice care. Clinical Record 5: The election of benefit was dated 01/09/2024 with a diagnosis of Alzheimer’s Disease, unspecified. A review of the clinical record revealed for the benefit period 07/17/2024 to 09/14/2024 the face-to-face was done on 07/09/2024 and recertification of terminal illness (CTI) was done on 07/08/2024(1 day after the CTI) and for the benefit period 09/15/2024 to 11/13/2024 the face-to-face was done on 09/06/2024 (1 day after the CTI) and the recertification of terminal illness was done on 09/05/2024. During an interview with the Administrator/Nurse Practitioner on 10/23/2024 she stated that she was unaware that the face-to-face needed to be done so that the Hospice medical director could review prior to writing the recertification of terminal illness.”

“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; The patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was a live discharge revealed that that agency did not ensure that a complete discharge summary was completed and provided to the attending physician. The agency’s policy titled Administrative Policy Manual, Patient Discharge PE.20 stated in part “The Hospice will forward copies of the following to the patient’s attending physician upon revocation and discharge from the Hospice’s services: The hospice discharge summary which includes but is not limited to a summary of the patient’s care (pain management, symptoms and treatments), the patient’s current POC, including the current medication profile, the latest physician orders, and any other documentation requested or that may assist with the patient’s post-discharge continuity of care.” Clinical Record 13: The patient elected hospice on 08/09/2024. The patient signed a revocation of hospice services on 08/11/2024. The patient was admitted to the hospital as he wanted to seek aggressive treatment. The clinical record contained no evidence of a documented discharge summary or a discharge summary sent to patient’s attending physician in accordance with agency policy. Clinical Record 14: The patient elected hospice on 01/12/2024. The patient was transferred to another hospice on 09/03/2024. The clinical record contained no evidence of a documented discharge summary and no documented evidence of a discharge summary being sent to the patient’s attending physician. During an interview with the Administrator on 10/23/2024 regarding the discharge summary, she stated I did not realize we needed to have a discharge summary.”

“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; 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, document review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was admitted to another facility, the agency did not ensure a discharge summary was sent to the receiving facility. Clinical Record 13: The patient elected hospice services on 08/09/2024. The patient signed a revocation of hospice services on 08/11/2024. The patient was admitted to the hospital to seek aggressive treatment. There was no documented evidence that a discharge summary was sent to the facility receiving the hospice patient. Clinical Record 14: The patient elected hospice services on 01/12/2024. The patient was transferred to another hospice on 09/03/2024. There was no documented evidence that a discharge summary was sent to the facility receiving the hospice patient. During an interview with the Administrator on 10/23/2024 regarding the discharge summary, she stated, “I did not realize we needed to have a discharge summary.””

“It is required that a hospice that provides short-term inpatient care under arrangement with a facility has a written agreement describing the arrangement and how the hospice coordinates the care; it includes at a minimum: The hospice provides a copy of the patient’s plan care to the inpatient provider and specifies the inpatient services to be provided. The inpatient provider establishes patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients. This standard was not met as evidenced by document review and interview. A review of agency contracts revealed there was no documented evidence of a contract for short-term inpatient care in all patient service areas. During an interview with the administrator on 10/24/2024 she stated that she was unaware that she needed to have a contract in that area also, but that it makes sense to provide the increased level of care when and if needed. Also, states that she will start working on obtaining a contract in that area immediately. A review of agency contracts revealed that no contract was present for short-term inpatient care in all patient service areas.”

“It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by clinical record review, document review and interview. In 11 of 11 (100%) clinical records reviewed for patients who elected social worker services revealed the agency did not ensure that a bachelor’s degree social worker (BSW) was supervised by CMS-qualified MSW. The agency’s policy titled Administrative Policy Manual, Employee Supervision HR.60 stated in part “A master’s prepared social worker (MSW) will provide supervision as required to the bachelor’s prepared social worker assistant and/or as frequently as indicated by the State practice act or based on patient acuity. Supervision may occur in person, over the telephone, through electronic communication, or any combination thereof.” Clinical Record 2: The hospice benefit was elected on 02/03/2024. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 3: The hospice benefit was elected on 08/08/2024. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 4: The hospice benefit was elected on 09/14/2024. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 5: The hospice benefit was elected on 01/19/2024. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 7: The hospice benefit was elected on 04/01/2024. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 8: The hospice benefit was elected on 10/11/2023. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 10: The hospice benefit was elected on 07/24/2024. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 11: The hospice benefit was elected on 03/24/2023. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 12: The hospice benefit was elected on 05/25/2023. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. Clinical Record 13: The hospice benefit was elected on 08/09/2024. Social worker services were being provided by a BSW. no evidence of MSW supervision was noted in the clinical record. Clinical Record 14: The hospice benefit was elected on 01/12/2024. Social worker services were being provided by a BSW. There was no documented evidence of MSW supervision in the clinical record. During an interview with the Administrator on 10/23/2024 regarding MSW supervision of the BSW she stated that there was a signed form in the personnel record (personnel record 7) that stated the BSW would be supervised stated she thought this was enough and was unaware supervision needed to be documented.”