New Star Hospice

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address informing local and state emergency officials of any on-duty employees that the hospice is unable to contact; This standard was not met as evidenced by document review and interview. A review of the hospice’s Emergency Plan dated August 2024 identified that the plan did not include a provision to track on-duty employees and when local emergency officials would be notified or when local officials would be notified if any on-duty employees were unable to be reached. The agency’s “Emergency Operations Plan and Policies (2.1.1),” dated February 2022 and reviewed/approved on 01/20/2025, read in part that “ ..Hospice will track patients and staff by telephone or in-person during an emergency. Hospice will inform state and local officials of any on-duty staff … they are unable to contact.” During a joint review of the Emergency Plan and an interview with the agency’s Administrator (Personnel Record 1) on 02/28/2025, she confirmed that the plan did not include a process for tracking on-duty staff or when or who would be notified of lost contact. A review of the hospice’s Emergency Plan dated August 2024 revealed that the plan did not include a provision to track on-duty employees and when local emergency officials would be notified or when local officials would be notified if any on-duty employees were unable to be reached. During a joint review of the Emergency Plan and an interview with the agency’s Administrator (Personnel Record 1) on 02/28/2025, she confirmed that the plan did not include a process for tracking on-duty staff or when or who would be notified of lost contact. The agency’s “Emergency Operations Plan and Policies (2.1.1),” dated February 2022 and reviewed/approved on 01/20/2025, read in part that “ ..Hospice will track patients and staff by telephone or in-person during an emergency. Hospice will inform state and local officials of any on-duty staff … they are unable to contact.””

“It is required that the hospice implements emergency preparedness (EP) policies and procedures based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address arrangements with facilities and other providers to receive patients to maintain the continuity of care to patients. This standard was not met as evidenced by document review and interview. The agency’s “Emergency Operations Plan and Policies (2.1.1),” dated February 2022 and reviewed/approved on 01/20/2025, read in part that “ . Hospice has prearranged transfer agreements … to receive patients in the event of limitations or cessation of operations to maintain the continuity of services...” A review of the hospice’s Emergency Plan dated August 2024 identified that the plan did not include an arrangement with another hospice to assume the care of the agency’s patients if they could not continue to care for them due to an emergency. During a joint review of the Emergency Plan and an interview with the agency’s Administrator (Personnel Record 1) on 02/28/2025, she confirmed that no such agreement currently existed with another hospice agency or any facility. A review of the hospice’s Emergency Plan dated August 2024 revealed that the plan did not include an arrangement with another hospice to assume the care of the agency’s patients if they could not continue to care for them due to an emergency. During a joint review of the Emergency Plan and an interview with the agency’s Administrator (Personnel Record 1) on 02/28/2025, she confirmed that no such agreement currently existed with another hospice agency or any facility. The agency’s “Emergency Operations Plan and Policies (2.1.1),” dated February 2022 and reviewed/approved on 01/20/2025, read in part that “ .. Hospice has prearranged transfer agreements … to receive patients in the event of limitations or cessation of operations to maintain the continuity of services...””

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 9 (11%) clinical records reviewed revealed the agency did not ensure the plans of care contained individualized interventions based on problems identified within the comprehensive assessments. AGENCY POLICY: The hospice’s policy “Interdisciplinary Group (IDG) Care Planning Process (9.12.1) dated February 2022 and reviewed/accepted 01/20/2025 included in part that “In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, The hospice will utilize data/information in the care planning process to provide care that is consistent with the patient and family needs, with patient’s needs and goals as a priority. The RN ensures that the plan of care is individualized, updated and relevant to the needs of the patient/family by documenting and reviewing patient care goals/objectives in a timely manner … Developing and revising patient care goals/objectives …” CLINICAL RECORD 2: The patient, who resided in a personal care home, elected the hospice benefit on 07/26/2024 with the diagnosis of cerebral infarction due to a thrombus. The plans of care for the benefit periods 07/26/2024 to 10/23/2024, 10/24/2024 to 01/21/2025, and 01/22/2025 to 03/22/2025 were reviewed. During the social worker’s visit on 07/30/2024, he noted in part that the “Wife reported patient can be combative and irritable. She is tired at times caring for patient. Patient does not have much support.” On 10/18/2024, the Registered Nurse (RN) documented in part that the “ CG reported patient always ripped off diaper in the night and plays in feces sometimes, able to relieve by lorazepam 1mg.” During the Interdisciplinary Group Meeting (IDG) on 10/18/2024, the nurse noted that the “Patient sometimes yelling at facility staff.” On 12/13/2024 during IDG the nurse documented in part that the “patient continues having episodes of ripped off diaper and touching feces per Caregiver, but able to relieve by Lorazepam.” Physician orders dated 07/26/2024 included Lorazepam 0.5mg tablets: one to two tablets by mouth every 2 hours as needed for anxiety, Citalopram 10mg by mouth daily for depression, and Donepezil Hydrochloride 5mg daily by mouth for dementia. On 10/16/2024 a scheduled order for Lorazepam 1mg by mouth daily for agitation was documented. The identified problem list for this patient included incontinence, skin breakdown, seizures, falls/safety, and a right eye infection. There was no documented evidence in the clinical record that the plan of care was updated for interventions or goals related to the identified problems during the comprehensive assessments associated with the patient’s agitation and/or behavioral issues requiring medication. During a joint clinical record review and interview with the Director of Nursing (Personnel Record 2) on 02/27/2025 that the patient’s plan of care did not include interventions or goals for the identified problem behaviors or agitation.”

“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, document review, and interview. In 2 of 7 (29%) applicable clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure that the registered nurse (RN) provided specific instructions to the aide in the aide plan of care. AGENCY POLICY: The agency’s policy “Hospice Aide Services and Training Program (4.20.1)” dated February 2022 and reviewed and approved on 01/20/2025 read in part that “... Hospice Aides are assigned to a specific patient by an RN (Registered Nurse) … written patient care instructions for a Hospice Aide must be prepared by an RN who is responsible for the supervision of the Hospice Aide...” The hospice’s policy dated February 2022 and reviewed/approved by the agency on 01/20/2025 entitled “Guidelines for COVID-19 Virus (5.20.1)” included in part that during “... Home Visits … Staff must utilize appropriate PPE per current CDC guidelines … Transmission-based precautions are implemented when a patient develops signs and symptoms of a transmissible or communicable infection … Transmission based precautions are additional measures taken to protect healthcare workers and patients …” CLINICAL RECORD 1: The patient, who resided at home, elected the hospice benefit on 01/27/2024 with the diagnosis of primary lateral sclerosis. The plans of care for the benefit periods 04/27/2024 to 07/26/2024 and 07/27/2024 to 09/25/2024 were reviewed and included orders for the hospice aide to visit the patient twice a week. On 07/22/2024, during the Registered Nurse (RN) visit, the nurse noted “...PRN visit for patient has fever … patient has productive cough with white mucous and congested. The wife reported that patient has fever since yesterday and the wife is positive for COVID since three days ago … test kit done for patient during visit, its positive, MD notified …” A physician’s order was documented on 07/22/2024 for Paxlovid (Nirmatrelvir 150mg/Ritonavir 100mg): three tablets twice a day by mouth for five days. There were hospice aide visits on 07/22/2024 and 07/26/2024 during the time that the patient had an active COVID-19 infection documented. The Hospice Aide Care Plan was updated on 07/24/2024 and included that the patient conditions that required changes to the hospice aide interventions were that the “patient has contractures to right hand and left leg, patient is bedbound, total assistance for all ADLs, patient constantly scratch.” The update did not include any COVID transmission-based precautions, nor did the previous aide care plan before the documented update on 07/24/2024. CLINICAL RECORD 2: The patient, who resided in a personal care home, elected the hospice benefit on 07/26/2024 with the diagnosis of cerebral infarction due to a thrombus. The plan of care for the benefit period 01/22/2025 to 03/22/2025 was reviewed and included twice weekly hospice aide visits. The Hospice Aide Care Plan dated 01/13/2025 included the task to shower the patient twice a week. During the Registered Nurse (RN) visit on 02/10/2025, the nurse assessed a stage two right heel pressure ulcer measuring 0.5cm x 0.6cm x 0.1cm. A physician’s order dated 02/10/2025 included instructions to cleanse the right heel stage two pressure ulcer with normal saline, pat dry, cover with a dry dressing three times a week, and change the dressing if it became soiled. There were hospice aide visits on 02/13/2025, 02/16/2025, and 02/20/2025 during the time that the patient’s wound was active. On 02/24/2025, the nurse noted the wound had healed, and the physician’s order was discontinued. There was no documented evidence that the aide care plan was updated to include instructions for the aide related to the wounds during the patient’s shower. It was confirmed during a joint clinical record review and interview with the Director of Nursing (Personnel Record 2) on 02/27/2024 that the aide care plans were not updated with instructions to the aide regarding COVID precautions or instructions for the patient’s wound and dressing.”

“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. Each patient’s record included physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) applicable clinical record reviewed in which the patient was a live discharge from hospice services revealed the agency did not ensure that a discharge order from the medical director was documented in accordance with its policy. AGENCY POLICY: The agency’s policy “Discharge Criteria (9.28.1)” dated February 2022 and reviewed on 01/20/2025 included in part that “... Prior to discharge … the IDG will obtain a written discharge order from the Medical Director...” CLINICAL RECORD 5: The patient, who resided at home, elected the hospice benefit on 02/04/2024 with the diagnosis of cerebral infarction. He was discharged from hospice services on 06/27/2024 to move out of the country. A review of the patient’s clinical record did not include a signed revocation form or a discharge order from the hospice’s Medical Director in accordance with agency policy. During a joint clinical record review and an interview with the Director of Nursing (Personnel Record 2) on 02/27/2025 it was confirmed that there was no signed revocation for or a discharge order from the hospice’s Medical Director at the time of the clinical record review.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 2 (50%) applicable clinical records reviewed in which there was a live discharge from the hospice, the agency did not ensure that the discharge summary was provided to the patient/family to assist with continuity of care during the patient’s move. AGENCY POLICY: The hospice’s policy “Discharge Criteria (9.28.1)” dated February 2022 and reviewed and adopted 01/20/2025, read in part that “... 1. Patient will be discharged from services as follows: … patient expired, patient revokes, patient moves out of Hospice’s service area …. Prior to discharge a patient for any reason listed in #1, the IDG will obtain a written discharge order from the Medical Director... Staff will be knowledgeable about discharge procedures, including instructions and follow-up responsibilities. The patient’s continuing care needs, if any, are assessed at discharge. The patient will receive verbal or written discharge instructions. A complete list of reconciled medications will be provided to each patient on discharge. The list will be explained to the patient/family, and the interaction will be documented...” CLINICAL RECORD 5: The patient, who resided at home, elected the hospice benefit on 02/04/2024 with the diagnosis of cerebral infarction. He was discharged from hospice services on 06/27/2024 due to moving out of the country. At the time of record review, the clinical visits, nurse notes, and scanned documents revealed no documented evidence that the discharge summary with the plan of care, physician orders, and medication list was provided to the family upon discharge. During a joint clinical record review and interview with the Director of Nursing (Personnel Record 2) on 2/27/2025 it was confirmed that no information was provided to the patient/family at the time of the discharge from the hospice to ensure continuity of care during the patient’s move-out of the country.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) applicable clinical records in which there was a live discharge from hospice services the agency did not ensure that the patient’s discharge summary included the required elements. AGENCY POLICY: The agency’s policy “Discharge Summary (9.29.1) dated February 2022 and reviewed and approved by the hospice on 01/20/2025 read in part that “... the Hospice Discharge summary will include... the date and reason for discharge, any instructions or referral information given to the patient or family... patient’s physician, hospice diagnosis, significant health history, discharge orders, instructions, medication profile, and allergies if discharge is other than patient death, a brief description of services provided any ongoing needs that cannot be met, presence of Advance Directives...” CLINICAL RECORD 5: The patient, who resided at home, elected the hospice benefit on 02/04/2024 with the diagnosis of cerebral infarction. He was discharged from hospice services on 06/27/2024 due to moving out of the country. The discharge summary documented on paper and dated 06/26/2024 included “Pt had UTI (urinary tract infection) on 6/16/24. MD ordered Cipro 250mg Q12 x 3 days.” In the area of the document with the header “Current reconciled medication profile attached,” it was left blank and a current medication profile was not included in the discharge summary. Latest physician orders: Pt had UTI (urinary tract infection) on 6/16/24. MD ordered Cipro 250mg Q12 x 3 days.” In the area of the document with the header “Current reconciled medication profile attached,” it was left blank. At the time of discharge, the patient’s medication list included: Digoxin 0.125mg by mouth daily, Finasteride 5mg by mouth daily, Atorvastatin 40mg by mouth daily, 24-hour Metoprolol Succinate ER 25mg by mouth every twelve hours, Apixaban 2.5mg by mouth every twelve hours, Tamsulosin Hydrochloride 0.4mg by mouth daily, Lorazepam 0.5mg: one to two tablets by mouth every two hours as needed for anxiety, Promethazine Hydrochloride 25mg by mouth every eight hours as needed for nausea/vomiting, and Senna-S (50mg/8.6mg): 1 capsule twice a day by mouth. PERSONNEL RECORD 2: During a joint clinical record review and interview with the Director of Nursing (Personnel Record 2) on 02/27/2025, she confirmed that the discharge summary documented in the clinical record did not include the plan of care with physician orders or the patient’s medication list and that no other documentation existed at the time of clinical record review.”

“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 clinical record may be maintained electronically. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews revealed the hospice: Failed to ensure the clinical record included documentation of a written and signed recertification of the terminal illness completed by the medical director no later than two (2) calendar days after the first day of each benefit period and no more than 15 days before the next benefit period began{HCPC.6.I/L676}. 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 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that short-term inpatient care is available for pain control, symptom management, and respite purposes. The hospice has criteria for general inpatient care and for respite admissions. Inpatient care is provided in a participating Medicare or Medicaid facility. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by document review and interview revealed the hospice: Failed to ensure that the agency had a written agreement describing the short-term inpatient care with a facility and how the hospice coordinates the care {HSIC.5. G/L716}. 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 counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. 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 and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed for patients who expired on service, the agency did not ensure that a bereavement risk assessment and associated Bereavement Plan of Care had been completed and implemented upon the patient’s death. Clinical Record 7: The election of benefit was 02/21/2024 with diagnoses of Congestive Heart Failure, Anorexia, weight loss Stage two pressure ulcer at the sacrum, and lung mass. The patient died on 07/03/2024. . The clinical record lacked evidence of a bereavement risk assessment and associated Bereavement Plan of Care upon death. In an interview on 10/10/2024 with the Administrator and the Clinical Manager, the Clinical Manager was unsure why the bereavement risk assessment was not completed or a plan of care for bereavement was implemented.”

“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. The recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed revealed that the agency did not ensure that the physician’s recertification of terminal illness was completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. Clinical Record 3: The election of benefit (EOB) was 01/27/2024.with diagnoses Primary Lateral Sclerosis, Chronic Idiopathic constipation, CVA, Dementia and Progressive Supranuclear Palsy. A review of the clinical record revealed there was no documented evidence of the physician recertification of terminal illness for the benefit period 04/28/2024 to 07/15/2024 or the third benefit period 07/16/2024 to 9/14/24. The hospice services continued through the benefit periods. Clinical Record 4: The EOB was 02/04/2024 with diagnoses of Cerebral Infarction, Dysphagia, HTN, and Atrial Fib. The patient was discharged on 06/27/2024. A review of the clinical record revealed there was no documented evidence of the physician recertification of terminal illness for the benefit period 05/06/2024. The hospice services continued through the benefit periods until the patient was discharged on06/27/2024. Clinical Record 7: The EOB was 02/21/2024 with diagnoses of Congestive Heart Failure, Anorexia, weight loss Stage two pressure ulcer at the sacrum, and lung mass. The patient died on 07/03/2024. A review of the clinical record revealed there was no documented evidence of the physician recertification of terminal illness for the benefit period 05/23/2024 to 08/20/2024. The hospice services continued through the benefit periods until the patient died on 07/03/2024. In an interview with the Clinical Manager (CM) on 10/09/2024, the CM stated that the EMR company informed them that they did not have to do the recertifications until they started billing and that the EMR company would update the agency’s software at that time.”

“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 and the methods used by the hospice to ensure the preceding requirements are met. This standard was not met as evidenced by document review and interview. A review of the agency did not ensure that short-term inpatient care under arrangement with a facility has a written agreement describing the arrangement and how the hospice coordinates the care. A review of the agency’s contracts did not include a written agreement with a facility for short-term inpatient care. In an interview with the Administrator and the Clinical Manager on 10/10/2024, the arrangement is pending but has not been completed.”