New Life Hospice

“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, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 10: The patient elected the hospice benefit on 09/18/2024. The Registered Nurse (RN) documented the nursing initial assessment on 09/18/2024. The documentation in the nursing initial assessment did not include a comprehensive psychosocial assessment. The Medical Social Worker (MSW) documented a comprehensive psychosocial assessment on 09/24/2024, 6 days after the start of hospice care and 1 day outstanding. The clinical record contained no documented evidence that the MSW communicated with the patient’s family regarding the delay in visits, or documentation of communication with the attending physician. During an interview and record review on 11/07/2024, the Administrator stated, “The MSW did perform the assessments later than the five days after the election of benefits.” The Administrator said she spoke with the MSW, and the patient’s family requested a later visit, but the MSW did not document the communication with the patient’s family member to schedule the visits beyond the five days.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as, hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy for Hand Hygiene, dated 09/01/2024, required in part, “Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub routinely, decontaminating hands in the clinical situations described below: 2. Immediately before touching a patient. 6. After touching a patient of the patient’s immediate environment.” Home Visit 1: During the home visit observation on 11/05/2024 with the Chaplain (Personnel Record 7), the Chaplain was observed to carry a cell phone, a small tablet, and a pen into the patient’s home. The Chaplain entered the home and did not sanitize hands before contact with the patient. At the end of the visit, the Chaplain prayed with the patient and maintained physical contact with the patient during the prayer. The Chaplain proceeded to pick up the cell phone, the pen and the tablet without disinfecting hands following patient contact. The Chaplain ended the visit and left the patient’s home. The Chaplain was interviewed following the home visit observation on 11/05/2024. The Chaplain stated that he did have access to alcohol-based hand sanitizer, and usually would wear a small bottle on a clip attached to his belt/belt loop. The Chaplain stated, “The hand sanitizer was left in the car.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse (RN) provided the Hospice Aide (HA) with patient specific written care instructions. Clinical Record 2: A review of the clinical record revealed that the Hospice Aide plan of care dated 10/09/2024 included instructions for the Hospice Aide to “Apply barrier cream to ___ [left blank].” The instruction did not include a specific location for the application of the barrier cream and there was no documented evidence in the clinical record of communication between the RN and the HA related to the application of barrier cream. Clinical Record 3: A review of the clinical record revealed that the Hospice Aide plan of care dated 10/22/2024 included instructions for the Hospice Aide to “Apply barrier cream to ___ [left blank].” The instruction did not include a specific location for the application of the barrier cream and there was no documented evidence in the clinical record of communication between the RN and the HA related to the application of barrier cream. Clinical Record 4: A review of the clinical record revealed that the Hospice Aide plan of care dated 07/05/2024 included instructions for the Hospice Aide to “Apply barrier cream to ___ [left blank].” The instruction did not include a specific location for the application of the barrier cream and there was no documented evidence in the clinical record of communication between the RN and the HA related to the application of barrier cream. During an interview and record review on 11/07/2024, the Administrator stated “The same nurse created the aide plans of care for these patients. The nurse didn’t include the location that the aide was to apply the barrier cream.””

“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. The agency did not ensure that hospice volunteers provided, at a minimum five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Review of agency documents for utilization of volunteer services over the past 12 months included documentation of volunteer usage for quarter 1 at 0.20%, for quarter 2 at 2.44%, for quarter 3 at 0.73%, and for quarter 4 at 2.91%. During an interview and discussion of the agency’s volunteer program on 11/07/2024, the Administrator stated that utilization of volunteers has been low, but they have volunteers who are trained and ready. The Administrator also stated there are a few more volunteers that will be onboarded this month and expects utilization to increase quickly. The Volunteer Coordinator also provided a plan for the recruitment and retention of new and existing volunteers. The agency did not ensure that hospice volunteers provided, at minimum five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with patient discharge, the agency did not ensure that the receiving facility was provided with a copy of the hospice discharge summary. Clinical Record 11: The patient elected the hospice benefit on 02/15/2024. The patient revoked the hospice benefit and was admitted to the hospital on 05/04/2024. There was no documented evidence in the clinical record that the discharge summary was sent to the receiving facility. During an interview and record review on 11/07/2024, the Administrator stated, “Someone in the office usually sends the discharge summary to the hospital. Whoever did it should have documented that it was sent.””