Assured Hospice

“. Based on document review, record reviews, and interview, the agency failed to notify the patients physician of missed services resulting in changes to the patients plan of care in 3 of 14 patients (Patient #8, Patient #9, and Patient #13). Failure to communicate with the patients physician of changes to the plan of care may potentially have a clinical impact on the patients medical needs. Findings included: 1. Document review of the agencys policy titled, “;Plan of Care,” (Policy #3.003, Revised date: 10/01/24) showed the plan of care include the detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. 2. Record review of active patient records of Patient #8, Patient #9, and Patient #13 showed: a. Patient #8 was admitted on 08/02/24 with a primary diagnosis of Colon Cancer. Skilled Nursing (SN) services were ordered with frequencies of 2 times a week for 10 weeks, then 3 times a week for 1 week, then 2 times a week for 1 week, and 1 time a week for 1 week starting 08/04/24. There was no documentation as to why only 1 of the 2 ordered SN visits were made during the Medicare weeks of 08/04/24 to 08/10/24 and 08/11/24 to 08/17/24, and no physician notification of the missed visits. In addition, there was no documentation as to why there were no SN visits made during the Medicare weeks of 08/25/24 to 08/31/24 and 09/01/24 to 09/07/24, and no physician notification of the missed visits. b. Patient #9 was admitted on 08/13/24 with a primary diagnosis of Right Breast Cancer. Hospice Aide (HA) services were ordered with frequencies of 1 time a week for 1 week, then 2 times a week for 12 weeks starting 08/18/24. There was no documentation as to why only 1 of 2 HA visits were made during the Medicare week of 09/01/24 to 09/07/24, and no physician notification of the missed visit. c. Patient #13 was admitted on 08/16/24 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. SN services were ordered with frequencies of 1 time a week for 1 week, then 2 times a week for 12 weeks, then 1 time a week for 1 week starting 08/18/24. There was no documentation as to why only 1 of 2 SN visits were made during the Medicare week of 09/08/24 to 09/14/24, and no physician notification of the missed visit. 3. On 10/31/24 at 8:45 AM, Surveyor #1 interviewed the agencys Executive Director (Staff #113) regarding the lack of documentation and physician notification of the missed services. Staff #113 acknowledged the findings and was unable to provide documentation of why the missed services occurred and why the patients physicians were not notified. .”

“. Based on document review, record review and interview, the agency failed to develop policies and procedures (P&P) in compliance with conducting an annual Tuberculosis (TB) assessment using a Department of Health (DOH) approved risk assessment form and failed to conduct an annual TB risk assessment for 4 of 4 volunteers (Volunteer #9, Volunteer #10, Volunteer #11, and Volunteer #12). Failure to conduct annual TB risk assessment screening on volunteers may place the clients and staff at risk of exposure to infectious diseases. Findings included: 1. Document review of the agencys P&P showed no policy that describes conducting an annual TB risk assessment using a DOH-approved risk assessment form. 2. The personnel record review for the 4 of 4 volunteers (Volunteer #9, Volunteer #10, Volunteer #11, and Volunteer #12) showed: a. Volunteer #9 was hired on 09/07/22. There was no documentation that a DOH-approved TB risk assessment was completed during the year 2023. b. Volunteer #10 was hired on 11/18/22. There was no documentation that a DOH-approved TB risk assessment was completed during the year 2023. c. Volunteer #11 was hired on 06/06/22. There was no documentation that a DOH-approved TB risk assessment was completed during the year 2023. d. Volunteer #12 was hired on 10/08/18. There was no documentation that a DOH-approved TB risk assessment was completed during the year 2023. 3. Surveyor #1 conducted interviews with the Volunteer Manager and the agency’s Executive Director that showed: a. On 10/29/24 at 10:30 AM, Surveyor #1 interviewed the agencys Volunteer Manager (Staff #114) on the missing annual TB risk assessment in 2023 on volunteers. Staff #114 acknowledged the findings and was unable to provide documentation. b. On 10/31/24 at 9:00 AM, Surveyor #1 interviewed the agency’s Executive Director (Staff #113) on the lack of TB risk screening policy. Staff #113 acknowledged that the current agency TB form screening is used as the policy that the agency follows but was unable to provide agency documentation on current TB risk screening policy. .”

“. Based on document review, record reviews and interview, the agency failed to obtain the Advance Directives for the patients’ medical records for 4 of 14 active patients (Patient #5, Patient #11, Patient #13, and Patient #14). Failure to have patient Advanced Directives documented in their record puts patients at risk of psychological or physical harm from improper or unwanted levels of care. Findings included: 1. Document review of the agencys policy titled, “;Advance Directives,” (Policy #1.007, Revised date: 09/01/23) showed the agency will obtain copies of the patients Advance Directives for the patients medical record. 2. Record review of patients (Patient #5, Patient #11, Patient #13, and Patient #14) showed: a. Patient #5 was admitted on 08/28/24. During the Skilled Nursing (SN) initial comprehensive assessment, there was documentation that the patient has Advance Directives. However, the agency failed to obtain copies of the Advance Directives for the patients medical records. b. Patient #11 was admitted on 09/30/24. During the Social Worker (MSW) initial assessment, there was documentation that the patient has Advance Directives. However, the agency failed to obtain copies of the Advance Directives for the patient medical records. c. Patient #13 was admitted on 08/16/24. During the SN initial comprehensive assessment, there was documentation that the patient has Advance Directives. However, the agency failed to obtain copies of the Advance Directives for the patient medical records. d. Patient #14 was admitted on 08/21/24. During the SN initial comprehensive assessment, there was documentation that the patient has Advance Directives. However, the agency failed to obtain copies of the Advance Directives for the patient medical records. 3. On 10/31/24 at 8:45 AM Surveyor #1 interviewed the agencys Executive Director (Staff #113) regarding the lack of Advance Directives. Staff #113 acknowledged the findings and stated that they were not aware of the missing copies of Advance Directives in the patients medical records.”

“. Based on document review, record reviews, and interview, the agency failed to complete missed visits in a timely manner for of 14 active patients (Patient #1, Patient #2, Patient #3, Patient #8, Patient #9, and Patient #13). Failure to maintain missed visits in a timely manner puts patients at risk of not meeting their medical needs. Findings included: 1. Document review of the agencys policy titled, “;Hospice Medical Record,” (Policy #9.001, Revised date: 10/01/24) showed to preserve the integrity of the documentation it should be completed and submitted within 24 hours. 2. Record review of patients (Patient #1, Patient #2, Patient #3, Patient #8, Patient #9, and Patient #13) showed: a. Patient #1 was admitted on 11/24/23. Documentation showed the patient refused a Skilled Nursing (SN) visit on 04/08/24. Agency staff failed to document the missed visit until 04/11/24, 3 days after the missed visit. The record also showed that the patient missed a visit due to staff emergency/illness on 06/04/24. The agency staff failed to document the missed visit until 06/10/24, 6 days after the missed visit. b. Patient #2 was admitted on 06/07/24. Documentation showed no answer to the patients home on a missed Social Worker (MSW) visit on 08/30/24. Agency staff failed to document the missed visit until 09/03/24, 4 days after the missed visit. c. Patient #3 was admitted on 09/06/23. Documentation showed the patient refused a SN visit on 09/29/23. Agency staff failed to document the missed visit until 10/02/23, 3 days after the missed visit. d. Patient #8 was admitted on 08/02/24. Documentation showed: i. The patient refused a HA visit on 08/2/24. Agency staff failed to document the missed visit until 08/14/24, 12 days after the missed visit. ii. The patient refused a SN visit on 08/09/24. Agency staff failed to document the missed visit until 08/13/24, 4 days after the missed visit. iii. The patient refused a HA visit on 08/16/24. Agency staff failed to document the missed visit until 08/21/24, 5 days after the missed visit. iv. There was no answer to the patients door on a MSW missed visit on 08/30/24. Agency staff failed to document the missed visit until 09/03/24, 4 days after the missed visit. v. Documentation showed that a missed HA visit on 09/10/24 was not on the HAs schedule. Agency staff failed to document the missed visit until 09/12/24, 2 days after the missed visit. vi. The patient refused a HA visit on 09/13/24. Agency staff failed to document the missed visit until 09/15/24, 2 days after the missed visit. e. Patient #9 was admitted on 08/13/24. Documentation showed the patient missed an HA visit on 09/10/24 because of a medical appointment. Agency staff failed to document the missed visit until 09/12/24, 2 days after the missed visit. f. Patient #13 was admitted on 08/16/24. The patient refused MSW visit on 08/19/24. Agency staff failed to document the missed visit until 08/21/24, 2 days after the missed visit. 3. On 10/31/24 at 8:45 AM, Surveyor #1 interviewed the agencys Executive Director (Staff #113) regarding the untimely documentation of missed visits. Staff #113 acknowledged the findings and stated that documentation should be completed within 24 hours per the agency policy.”