Survey Report for 391649

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	391649	A. BUILDING __________ B. WING ______________	07/20/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
COMPASSUS - GREATER PHILADELPHIA	500 HAWK RIDGE ROAD, SUITE 6, HAMBURG, PA, 19526
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0513
L0513	40929 Based on a review of hospice policies/procedures, clinical records (CR), and an interview with the clinical director, the hospice failed to ensure patient and the patient's representative were involved in the hospice plan of care including discharge planning from hospice for one (1) of one (1) patients reviewed. CR #1 Findings Included: On 7/20/22 at approximately 11:30 AM, review of the hospice polices/procedures revealed the following: The policy titled, " Procedure: Discharge/Transfer/Revocation NOT related to missed Face to Face Evaluation " states, " A hospice may discharge a patient from services in only a few specific circumstances: The patient is deceased, the patient is no longer eligible due to a prognosis of greater than 6 months, the patient has moved out of the hospice ' s service area, the patient or other person in the patient ' s home exhibits behavior which is abusive, disruptive or uncooperative to the extent that delivery of care is seriously impaired or the patient/family refuse to permit a face-to-face assessment for the purpose of recertification as required by statute ...Procedure for discharge due to decertification (no longer eligible for hospice services due to extended prognosis beyond 6 months) ...the IDT is responsible for the ongoing assessment of the patient ' s hospice needs, including determinations about the patient ' s eligibility for services based on the physician ' s assessment about the patient ' s prognosis. At any time the prognosis is determined the be likely greater than 6 months, the IDT should begin discharge planning for decertification of the hospice benefit. It is best practice to ensure discussion and determination about ongoing eligibility at least 2 weeks prior to the recertification due date to ensure continuity of care. The discussion about the patient ' s eligibility for hospice services occurs during the IDT meetings and documentation reflects the ongoing determination by the physician and the IDT about continued eligibility. When it is determined the patient can no longer be certified for hospice services the IDT establishes the discharge plan to ensure safety and continuity of care. Consideration should include but not limited to: Medication needs, community resource needs, access to physician services/care support, transition for the patient back to previous community health providers ...provide a copy of the complete discharge summary to the patient ' s attending physician ...A complete discharge summary includes: discharge summary from the EMR, most recent plan of care, most recent medication list, any physician orders provided in the 2 weeks prior to discharge, including any post-discharge planning...For Medicare beneficiaries complete the Notice of Medicare Non-Coverage and schedule a visit by the nurse or SW to review with the patient/representative not less than 48 hours prior to the planned date of discharge. At a scheduled visit with the patient/representative, provide the Notice of Medicare Non-Coverage (NoMNC). NoMNC requires a signature from the patient/representative indicating only that they received the notification. If the patient/representative will not sign the document, the hospice team member must note this on the form with the specific date and time of the meeting and discussion. " A review of CR#1 was reviewed on 7/20/22 at approximately 10:00 AM which revealed: CR #1: Start of Care (SOC): 4/10/2020. Diagnoses include: Parkinsons Disease (a chronic and progressive movement disorder) and Dysphagia (a condition with difficulty in swallowing food or liquid). Discharge from hospice services on 7/15/22. Most recent recertification period: 5/30/22 through 7/28/22. Orders included for the following: Skilled Nursing twice weekly for nine weeks, Social Worker once monthly for 2 months, home health aides five times a week for eight weeks then four times a week for one week, and chaplain once monthly for two months. "Client coordination Notes" report revealed the following. A note by the Home Health Aide on 7/5/22 states, " (Daughter) asked about a list of agencies to help out when pts care prior to being discharged. Email sent to RNCM (Skilled Nurse Case Manager) and LPN (licensed practical nurse). " 7/8/22 note by LPN states, " Medications reconciled with caregiver ... " 7/11/22 note by LPN states, " Medication reconciled with caregiver and refills ordered this visit. Pt to be discharged from service due to extended prognosis. Competent to administer medications safely to this patient. Medication refills ordered. No further needs this visit. " 7/11/22 note by Social worker (SW) states , " late entry from 7/8/22 ...Husband had questions regarding pt ' s d/c (discharge) this Friday 7/15/22. SW educated husband that pt will d/c off of hospice services on Friday 7/15/22 due to extended prognosis and no longer meeting eligibility for hospice criteria. Husband expressed that pt has a PCP (primary care provider) in the community ...Husband did not identify any other needs at that time. Husband stated his daughter might have some questions for SW. SW provided husband with SW ' s work cell phone number. NOMNC (Notice of Medicare Non-Coverage) with d/c date 7/15/22 to be mail to home address on file. " On call RN from 7/13/22 note states, " Nurse practitioner was out today and ordered an antibiotic ... " additional not from same on call nurse on 7/13/22 states, " Called daughter with an ETA (estimated time of arrival), she informed me that she called Compassus to inform us of a change in her mother ' s condition...daughter declined visit this evening. " LPN note from 7/14/22 states, " Follow up visit with pt regarding change in status ...pt to be discharged on 7/15/22 due to extended prognosis. Daughter primary caregiver expressed concerns regarding HHA (Home Health Aide) services. This LPN will reach out to social services for assistance for this family ... " RN note from 7/15/22 states, " Pt noted with increased involuntary movements. Pain denies at present. Pt due to be discharged due to extended prognosis on 7/15/22 ...Pt has PCP in the community. No further needs at this time. " There was no additional SW notes after the late entry SW note on 7/11 that was for communication with the family on 7/8/22. Notice of Medicare Non-Coverage form reviewed on 7/20/22 at approximately 10:30AM. It states on form " SW talked to spouse about discharge on 7/13/22. NOMNC mailed to spouse ... " This form contains information on " Your right to appeal this decision " and " How to ask for an Immediate Appeal. This form is not yet signed by the patient or representative. There was nothing written on the form that the patient/representative refused to sign the form. During interview conducted on 7/20/22 at approximately 1:30 PM, the administrator confirmed the above findings.
L0540
L0540	40929 Based on a review of agency policy and procedures, clinical records (CR) and interview with the clinical director, the registered nurse failed to provide coordination of care by failing to update the patient's comprehensive assessment/IDG meeting documentation to show the patient's reason for discharge and subsequent discharge plan for one (1) of one (1) clinical records reviewed (CR #1). Findings included: Policy reviewed occurred on 7/20/22 at approximately 11:30 AM which revealed the following: The policy titled, " Procedure: Discharge/Transfer/Revocation NOT related to missed Face to Face Evaluation " states, " A hospice may discharge a patient from services in only a few specific circumstances: The patient is deceased, the patient is no longer eligible due to a prognosis of greater than 6 months, the patient has moved out of the hospice ' s service area, the patient or other person in the patient ' s home exhibits behavior which is abusive, disruptive or uncooperative to the extent that delivery of care is seriously impaired or the patient/family refuse to permit a face-to-face assessment for the purpose of recertification as required by statute ...Procedure for discharge due to decertification (no longer eligible for hospice services due to extended prognosis beyond 6 months) ...the IDT is responsible for the ongoing assessment of the patient ' s hospice needs, including determinations about the patient ' s eligibility for services based on the physician ' s assessment about the patient ' s prognosis. At any time the prognosis is determined the be likely greater than 6 months, the IDT should begin discharge planning for decertification of the hospice benefit. It is best practice to ensure discussion and determination about ongoing eligibility at least 2 weeks prior to the recertification due date to ensure continuity of care. The discussion about the patient ' s eligibility for hospice services occurs during the IDT meetings and documentation reflects the ongoing determination by the physician and the IDT about continued eligibility. When it is determined the patient can no longer be certified for hospice services the IDT establishes the discharge plan to ensure safety and continuity of care. Consideration should include but not limited to: Medication needs, community resource needs, access to physician services/care support, transition for the patient back to previous community health providers ...For Medicare beneficiaries complete the Notice of Medicare Non-Coverage and schedule a visit by the nurse or SW to review with the patient/representative not less than 48 hours prior to the planned date of discharge. At a scheduled visit with the patient/representative, provide the Notice of Medicare Non-Coverage (NoMNC). NoMNC requires a signature from the patient/representative indicating only that they received the notification. If the patient/representative will not sign the document, the hospice team member must note this on the form with the specific date and time of the meeting and discussion. " Policy titled, " Procedure: Clinical Eligibility Review and Escalation steps when additional review is needed " states, " The determination of eligibility and certification of terminal illness is the responsibility of the hospice physician. The hospice must use all available resources and patient data to make a determination of eligibility ...If the patient is to be reviewed for eligibility for a recertification determination, the RN case manager gathers patient assessment information, including objective and subjective details, to support the physician in decision making. Information provided to the physician should exist in the patient ' s clinical record- do not provide summation or extrapolation of information that is not supported in documentation. The final decision about a patient ' s eligibility, recertification, and continued receipt of hospice service rests with the program ' s hospice physician. The hospice team ' s clinical assessment and documentation are intended to support the decision-making process as well as provide clear direction for the development, implementation and update of the individual patient ' s plan of care ...The patient ' s clinical record is a repository for all documentation related to the patient ' s comfort, safety, and quality of life and it is the hospice team ' s role to ensure the provision of care is aligned with the patient ' s desired outcomes, individual goals and payer requirements for coverage " A review of CR#1 was reviewed on 7/20/22 at approximately 10:00 AM which revealed: CR #1: Start of Care (SOC): 4/10/2020 Diagnoses include: Parkinsons Disease (a chronic and progressive movement disorder) and Dysphagia (a condition with difficulty in swallowing food or liquid). Discharge from hospice services on 7/15/22. Most recent recertification period: 5/30/22 through 7/28/22. Orders included for the following: Skilled Nursing twice weekly for nine weeks, Social Worker once monthly for 2 months, home health aides five times a week for eight weeks then four times a week for one week, and chaplain once monthly for two months. Client coordination notes report revealed the following. A note by the Home Health Aide on 7/5/22 states, " (Daughter) asked about a list of agencies to help out when pts care prior to being discharged. Email sent to RNCM (Skilled Nurse Case Manager) and LPN (licensed practical nurse). " 7/11/22 note by Social worker (SW) states , " late entry from 7/8/22 ...Husband had questions regarding pt ' s d/c (discharge) this Friday 7/15/22. SW educated husband that pt will d/c off of hospice services on Friday 7/15/22 due to extended prognosis and no longer meeting eligibility for hospice criteria. Husband expressed that pt has a PCP (primary care provider) in the community ...Husband did not identify any other needs at that time. Husband stated his daughter might have some questions for SW. SW provided husband with SW ' s work cell phone number. NOMNC (Notice of Medicare Non-Coverage) with d/c date 7/15/22 to be mail to home address on file. " LPN note from 7/14/22 states, " Follow up visit with pt regarding change in status ...pt to be discharged on 7/15/22 due to extended prognosis. Daughter primary caregiver expressed concerns regarding HHA (Home Health Aide) services. This LPN will reach out to social services for assistance for this family ... " RN note from 7/15/22 states, " Pt noted with increased involuntary movements. Pain denies at present. Pt due to be discharged due to extended prognosis on 7/15/22 ...Pt has PCP in the community. No further needs at this time. " Most recent IDG meeting from 7/8/22 states the following from the Hospice physician, " Patient remains appropriate for hospice and continues to decline with a terminal dx (diagnosis) and poor prognosis. " File contained a verbal order written on 7/8/22 to discharge from the agency on 7/15/22. Physician has not signed yet. Per the clinical director he will sign at the next IDG meeting on 7/22/22. File did not contain any documented IDG discussion about the patient's discharge from hospice. In addition, the IDG meeting did not contain documentation of a hospice discharge plan. Interview was conducted with the clinical director on 7/20/22 at approximately 1:30 PM who confirmed the above findings.
L0544
L0544	40929 Based on a review of hospice policies/procedures, clinical records (CR), and an interview with the clinical director, the hospice failed to ensure patient and the patient's representative were involved in the hospice discharge prior to patient's discharge from hospice for one (1) of one (1) patients reviewed. CR #1 Findings Included: On 7/20/22 at approximately 11:30 AM, review of the hospice polices/procedures revealed the following: The policy titled, " Procedure: Discharge/Transfer/Revocation NOT related to missed Face to Face Evaluation " states, " A hospice may discharge a patient from services in only a few specific circumstances: The patient is deceased, the patient is no longer eligible due to a prognosis of greater than 6 months, the patient has moved out of the hospice ' s service area, the patient or other person in the patient ' s home exhibits behavior which is abusive, disruptive or uncooperative to the extent that delivery of care is seriously impaired or the patient/family refuse to permit a face-to-face assessment for the purpose of recertification as required by statute ...Procedure for discharge due to decertification (no longer eligible for hospice services due to extended prognosis beyond 6 months) ...the IDT is responsible for the ongoing assessment of the patient ' s hospice needs, including determinations about the patient ' s eligibility for services based on the physician ' s assessment about the patient ' s prognosis. At any time the prognosis is determined the be likely greater than 6 months, the IDT should begin discharge planning for decertification of the hospice benefit. It is best practice to ensure discussion and determination about ongoing eligibility at least 2 weeks prior to the recertification due date to ensure continuity of care. The discussion about the patient ' s eligibility for hospice services occurs during the IDT meetings and documentation reflects the ongoing determination by the physician and the IDT about continued eligibility. When it is determined the patient can no longer be certified for hospice services the IDT establishes the discharge plan to ensure safety and continuity of care. Consideration should include but not limited to: Medication needs, community resource needs, access to physician services/care support, transition for the patient back to previous community health providers ...provide a copy of the complete discharge summary to the patient ' s attending physician ...A complete discharge summary includes: discharge summary from the EMR, most recent plan of care, most recent medication list, any physician orders provided in the 2 weeks prior to discharge, including any post-discharge planning...For Medicare beneficiaries complete the Notice of Medicare Non-Coverage and schedule a visit by the nurse or SW to review with the patient/representative not less than 48 hours prior to the planned date of discharge. At a scheduled visit with the patient/representative, provide the Notice of Medicare Non-Coverage (NoMNC). NoMNC requires a signature from the patient/representative indicating only that they received the notification. If the patient/representative will not sign the document, the hospice team member must note this on the form with the specific date and time of the meeting and discussion. " A review of CR#1 was reviewed on 7/20/22 at approximately 10:00 AM which revealed: CR #1: Start of Care (SOC): 4/10/2020. Diagnoses include: Parkinsons Disease (a chronic and progressive movement disorder) and Dysphagia (a condition with difficulty in swallowing food or liquid). Discharge from hospice services on 7/15/22. Most recent recertification period: 5/30/22 through 7/28/22. Orders included for the following: Skilled Nursing twice weekly for nine weeks, Social Worker once monthly for 2 months, home health aides five times a week for eight weeks then four times a week for one week, and chaplain once monthly for two months. "Client coordination Notes" report revealed the following. A note by the Home Health Aide on 7/5/22 states, " (Daughter) asked about a list of agencies to help out when pts care prior to being discharged. Email sent to RNCM (Skilled Nurse Case Manager) and LPN (licensed practical nurse). " 7/8/22 note by LPN states, " Medications reconciled with caregiver ... " 7/11/22 note by LPN states, " Medication reconciled with caregiver and refills ordered this visit. Pt to be discharged from service due to extended prognosis. Competent to administer medications safely to this patient. Medication refills ordered. No further needs this visit. " 7/11/22 note by Social worker (SW) states , " late entry from 7/8/22 ...Husband had questions regarding pt ' s d/c (discharge) this Friday 7/15/22. SW educated husband that pt will d/c off of hospice services on Friday 7/15/22 due to extended prognosis and no longer meeting eligibility for hospice criteria. Husband expressed that pt has a PCP (primary care provider) in the community ...Husband did not identify any other needs at that time. Husband stated his daughter might have some questions for SW. SW provided husband with SW ' s work cell phone number. NOMNC (Notice of Medicare Non-Coverage) with d/c date 7/15/22 to be mail to home address on file. " On call RN from 7/13/22 note states, " Nurse practitioner was out today and ordered an antibiotic ... " additional not from same on call nurse on 7/13/22 states, " Called daughter with an ETA (estimated time of arrival), she informed me that she called Compassus to inform us of a change in her mother ' s condition...daughter declined visit this evening. " LPN note from 7/14/22 states, " Follow up visit with pt regarding change in status ...pt to be discharged on 7/15/22 due to extended prognosis. Daughter primary caregiver expressed concerns regarding HHA (Home Health Aide) services. This LPN will reach out to social services for assistance for this family ... " RN note from 7/15/22 states, " Pt noted with increased involuntary movements. Pain denies at present. Pt due to be discharged due to extended prognosis on 7/15/22 ...Pt has PCP in the community. No further needs at this time. " There was no additional SW notes after the late entry SW note on 7/11 that was for communication with the family on 7/8/22. Notice of Medicare Non-Coverage form reviewed on 7/20/22 at approximately 10:30AM. It states on form " SW talked to spouse about discharge on 7/13/22. NOMNC mailed to spouse ... " This form contains information on " Your right to appeal this decision " and " How to ask for an Immediate Appeal. This form is not yet signed by the patient or representative. There was nothing written on the form that the patient/representative refused to sign the form. During interview conducted on 7/20/22 at approximately 1:30 PM, the administrator confirmed the above findings.
L0553
L0553	40929 Based on a review of agency policy and procedures, clinical records (CR) and interview with the clinical director, the hospice and hospice physician failed to update the patient's comprehensive assessment/IDG meeting documentation to show the patient's reason for discharge and subsequent discharge plan for one (1) of one (1) clinical records reviewed (CR #1). Findings included: Policy reviewed occurred on 7/20/22 at approximately 11:30 AM which revealed the following: The policy titled, " Procedure: Discharge/Transfer/Revocation NOT related to missed Face to Face Evaluation " states, " A hospice may discharge a patient from services in only a few specific circumstances: The patient is deceased, the patient is no longer eligible due to a prognosis of greater than 6 months, the patient has moved out of the hospice ' s service area, the patient or other person in the patient ' s home exhibits behavior which is abusive, disruptive or uncooperative to the extent that delivery of care is seriously impaired or the patient/family refuse to permit a face-to-face assessment for the purpose of recertification as required by statute ...Procedure for discharge due to decertification (no longer eligible for hospice services due to extended prognosis beyond 6 months) ...the IDT is responsible for the ongoing assessment of the patient ' s hospice needs, including determinations about the patient ' s eligibility for services based on the physician ' s assessment about the patient ' s prognosis. At any time the prognosis is determined the be likely greater than 6 months, the IDT should begin discharge planning for decertification of the hospice benefit. It is best practice to ensure discussion and determination about ongoing eligibility at least 2 weeks prior to the recertification due date to ensure continuity of care. The discussion about the patient ' s eligibility for hospice services occurs during the IDT meetings and documentation reflects the ongoing determination by the physician and the IDT about continued eligibility. When it is determined the patient can no longer be certified for hospice services the IDT establishes the discharge plan to ensure safety and continuity of care. Consideration should include but not limited to: Medication needs, community resource needs, access to physician services/care support, transition for the patient back to previous community health providers ...For Medicare beneficiaries complete the Notice of Medicare Non-Coverage and schedule a visit by the nurse or SW to review with the patient/representative not less than 48 hours prior to the planned date of discharge. At a scheduled visit with the patient/representative, provide the Notice of Medicare Non-Coverage (NoMNC). NoMNC requires a signature from the patient/representative indicating only that they received the notification. If the patient/representative will not sign the document, the hospice team member must note this on the form with the specific date and time of the meeting and discussion. " Policy titled, " Procedure: Clinical Eligibility Review and Escalation steps when additional review is needed " states, " The determination of eligibility and certification of terminal illness is the responsibility of the hospice physician. The hospice must use all available resources and patient data to make a determination of eligibility ...If the patient is to be reviewed for eligibility for a recertification determination, the RN case manager gathers patient assessment information, including objective and subjective details, to support the physician in decision making. Information provided to the physician should exist in the patient ' s clinical record- do not provide summation or extrapolation of information that is not supported in documentation. The final decision about a patient ' s eligibility, recertification, and continued receipt of hospice service rests with the program ' s hospice physician. The hospice team ' s clinical assessment and documentation are intended to support the decision-making process as well as provide clear direction for the development, implementation and update of the individual patient ' s plan of care ...The patient ' s clinical record is a repository for all documentation related to the patient ' s comfort, safety, and quality of life and it is the hospice team ' s role to ensure the provision of care is aligned with the patient ' s desired outcomes, individual goals and payer requirements for coverage " A review of CR#1 was reviewed on 7/20/22 at approximately 10:00 AM which revealed: CR #1: Start of Care (SOC): 4/10/2020 Diagnoses include: Parkinsons Disease (a chronic and progressive movement disorder) and Dysphagia (a condition with difficulty in swallowing food or liquid). Discharge from hospice services on 7/15/22. Most recent recertification period: 5/30/22 through 7/28/22. Orders included for the following: Skilled Nursing twice weekly for nine weeks, Social Worker once monthly for 2 months, home health aides five times a week for eight weeks then four times a week for one week, and chaplain once monthly for two months. Client coordination notes report revealed the following. A note by the Home Health Aide on 7/5/22 states, " (Daughter) asked about a list of agencies to help out when pts care prior to being discharged. Email sent to RNCM (Skilled Nurse Case Manager) and LPN (licensed practical nurse). " 7/11/22 note by Social worker (SW) states , " late entry from 7/8/22 ...Husband had questions regarding pt ' s d/c (discharge) this Friday 7/15/22. SW educated husband that pt will d/c off of hospice services on Friday 7/15/22 due to extended prognosis and no longer meeting eligibility for hospice criteria. Husband expressed that pt has a PCP (primary care provider) in the community ...Husband did not identify any other needs at that time. Husband stated his daughter might have some questions for SW. SW provided husband with SW ' s work cell phone number. NOMNC (Notice of Medicare Non-Coverage) with d/c date 7/15/22 to be mail to home address on file. " LPN note from 7/14/22 states, " Follow up visit with pt regarding change in status ...pt to be discharged on 7/15/22 due to extended prognosis. Daughter primary caregiver expressed concerns regarding HHA (Home Health Aide) services. This LPN will reach out to social services for assistance for this family ... " RN note from 7/15/22 states, " Pt noted with increased involuntary movements. Pain denies at present. Pt due to be discharged due to extended prognosis on 7/15/22 ...Pt has PCP in the community. No further needs at this time. " Most recent IDG meeting from 7/8/22 states the following from the Hospice physician, " Patient remains appropriate for hospice and continues to decline with a terminal dx (diagnosis) and poor prognosis. " File contained a verbal order written on 7/8/22 to discharge from the agency on 7/15/22. Physician has not signed yet. Per the clinical director he will sign at the next IDG meeting on 7/22/22. File did not contain any documented IDG discussion about the patient's discharge from hospice. In addition, the IDG meeting did not contain documentation of a hospice discharge plan. Interview was conducted with the clinical director on 7/20/22 at approximately 1:30 PM who confirmed the above findings.
L0590
L0590	40929 Based on a review of agency policy and procedures, clinical records (CR) and interview with the clinical director, the hospice and hospice physician failed to update the patient's comprehensive assessment/IDG meeting documentation to show the patient's reason for discharge and subsequent discharge plan for one (1) of one (1) clinical records reviewed (CR #1). Findings included: Policy reviewed occurred on 7/20/22 at approximately 11:30 AM which revealed the following: The policy titled, " Procedure: Discharge/Transfer/Revocation NOT related to missed Face to Face Evaluation " states, " A hospice may discharge a patient from services in only a few specific circumstances: The patient is deceased, the patient is no longer eligible due to a prognosis of greater than 6 months, the patient has moved out of the hospice ' s service area, the patient or other person in the patient ' s home exhibits behavior which is abusive, disruptive or uncooperative to the extent that delivery of care is seriously impaired or the patient/family refuse to permit a face-to-face assessment for the purpose of recertification as required by statute ...Procedure for discharge due to decertification (no longer eligible for hospice services due to extended prognosis beyond 6 months) ...the IDT is responsible for the ongoing assessment of the patient ' s hospice needs, including determinations about the patient ' s eligibility for services based on the physician ' s assessment about the patient ' s prognosis. At any time the prognosis is determined the be likely greater than 6 months, the IDT should begin discharge planning for decertification of the hospice benefit. It is best practice to ensure discussion and determination about ongoing eligibility at least 2 weeks prior to the recertification due date to ensure continuity of care. The discussion about the patient ' s eligibility for hospice services occurs during the IDT meetings and documentation reflects the ongoing determination by the physician and the IDT about continued eligibility. When it is determined the patient can no longer be certified for hospice services the IDT establishes the discharge plan to ensure safety and continuity of care. Consideration should include but not limited to: Medication needs, community resource needs, access to physician services/care support, transition for the patient back to previous community health providers ...For Medicare beneficiaries complete the Notice of Medicare Non-Coverage and schedule a visit by the nurse or SW to review with the patient/representative not less than 48 hours prior to the planned date of discharge. At a scheduled visit with the patient/representative, provide the Notice of Medicare Non-Coverage (NoMNC). NoMNC requires a signature from the patient/representative indicating only that they received the notification. If the patient/representative will not sign the document, the hospice team member must note this on the form with the specific date and time of the meeting and discussion. " Policy titled, " Procedure: Clinical Eligibility Review and Escalation steps when additional review is needed " states, " The determination of eligibility and certification of terminal illness is the responsibility of the hospice physician. The hospice must use all available resources and patient data to make a determination of eligibility ...If the patient is to be reviewed for eligibility for a recertification determination, the RN case manager gathers patient assessment information, including objective and subjective details, to support the physician in decision making. Information provided to the physician should exist in the patient ' s clinical record- do not provide summation or extrapolation of information that is not supported in documentation. The final decision about a patient ' s eligibility, recertification, and continued receipt of hospice service rests with the program ' s hospice physician. The hospice team ' s clinical assessment and documentation are intended to support the decision-making process as well as provide clear direction for the development, implementation and update of the individual patient ' s plan of care ...The patient ' s clinical record is a repository for all documentation related to the patient ' s comfort, safety, and quality of life and it is the hospice team ' s role to ensure the provision of care is aligned with the patient ' s desired outcomes, individual goals and payer requirements for coverage " A review of CR#1 was reviewed on 7/20/22 at approximately 10:00 AM which revealed: CR #1: Start of Care (SOC): 4/10/2020. Diagnoses include: Parkinsons Disease (a chronic and progressive movement disorder) and Dysphagia (a condition with difficulty in swallowing food or liquid). Discharge from hospice services on 7/15/22. Most recent recertification period: 5/30/22 through 7/28/22. Orders included for the following: Skilled Nursing twice weekly for nine weeks, Social Worker once monthly for 2 months, home health aides five times a week for eight weeks then four times a week for one week, and chaplain once monthly for two months. Client coordination notes report revealed the following. A note by the Home Health Aide on 7/5/22 states, " (Daughter) asked about a list of agencies to help out when pts care prior to being discharged. Email sent to RNCM (Skilled Nurse Case Manager) and LPN (licensed practical nurse). " 7/11/22 note by Social worker (SW) states , " late entry from 7/8/22 ...Husband had questions regarding pt ' s d/c (discharge) this Friday 7/15/22. SW educated husband that pt will d/c off of hospice services on Friday 7/15/22 due to extended prognosis and no longer meeting eligibility for hospice criteria. Husband expressed that pt has a PCP (primary care provider) in the community ...Husband did not identify any other needs at that time. Husband stated his daughter might have some questions for SW. SW provided husband with SW ' s work cell phone number. NOMNC (Notice of Medicare Non-Coverage) with d/c date 7/15/22 to be mail to home address on file. " LPN note from 7/14/22 states, " Follow up visit with pt regarding change in status ...pt to be discharged on 7/15/22 due to extended prognosis. Daughter primary caregiver expressed concerns regarding HHA (Home Health Aide) services. This LPN will reach out to social services for assistance for this family ... " RN note from 7/15/22 states, " Pt noted with increased involuntary movements. Pain denies at present. Pt due to be discharged due to extended prognosis on 7/15/22 ...Pt has PCP in the community. No further needs at this time. " Most recent IDG meeting from 7/8/22 states the following from the Hospice physician, " Patient remains appropriate for hospice and continues to decline with a terminal dx (diagnosis) and poor prognosis. " File contained a verbal order written on 7/8/22 to discharge from the agency on 7/15/22. Physician has not signed yet. Per the clinical director he will sign at the next IDG meeting on 7/22/22. File did not contain any documented IDG discussion about the patient's discharge from hospice. In addition, the IDG meeting did not contain documentation of a hospice discharge plan. Interview was conducted with the clinical director on 7/20/22 at approximately 1:30 PM who confirmed the above findings.
L0594
L0594	40929 Based on a review of hospice policies/procedures, clinical records (CR), and an interview with the clinical director, the hospice social worker failed to follow the hospice's policy to ensure patient and the patient's representative were involved in the hospice discharge prior to patient's discharge from hospice for one (1) of one (1) patients reviewed. CR #1 Findings Included: On 7/20/22 at approximately 11:30 AM, review of the hospice polices/procedures revealed the following: The policy titled, " Procedure: Discharge/Transfer/Revocation NOT related to missed Face to Face Evaluation " states, " A hospice may discharge a patient from services in only a few specific circumstances: The patient is deceased, the patient is no longer eligible due to a prognosis of greater than 6 months, the patient has moved out of the hospice ' s service area, the patient or other person in the patient ' s home exhibits behavior which is abusive, disruptive or uncooperative to the extent that delivery of care is seriously impaired or the patient/family refuse to permit a face-to-face assessment for the purpose of recertification as required by statute ...Procedure for discharge due to decertification (no longer eligible for hospice services due to extended prognosis beyond 6 months) ...the IDT is responsible for the ongoing assessment of the patient ' s hospice needs, including determinations about the patient ' s eligibility for services based on the physician ' s assessment about the patient ' s prognosis. At any time the prognosis is determined the be likely greater than 6 months, the IDT should begin discharge planning for decertification of the hospice benefit. It is best practice to ensure discussion and determination about ongoing eligibility at least 2 weeks prior to the recertification due date to ensure continuity of care. The discussion about the patient ' s eligibility for hospice services occurs during the IDT meetings and documentation reflects the ongoing determination by the physician and the IDT about continued eligibility. When it is determined the patient can no longer be certified for hospice services the IDT establishes the discharge plan to ensure safety and continuity of care. Consideration should include but not limited to: Medication needs, community resource needs, access to physician services/care support, transition for the patient back to previous community health providers ...provide a copy of the complete discharge summary to the patient ' s attending physician ...A complete discharge summary includes: discharge summary from the EMR, most recent plan of care, most recent medication list, any physician orders provided in the 2 weeks prior to discharge, including any post-discharge planning...For Medicare beneficiaries complete the Notice of Medicare Non-Coverage and schedule a visit by the nurse or SW to review with the patient/representative not less than 48 hours prior to the planned date of discharge. At a scheduled visit with the patient/representative, provide the Notice of Medicare Non-Coverage (NoMNC). NoMNC requires a signature from the patient/representative indicating only that they received the notification. If the patient/representative will not sign the document, the hospice team member must note this on the form with the specific date and time of the meeting and discussion. " A review of CR#1 was reviewed on 7/20/22 at approximately 10:00 AM which revealed: CR #1: Start of Care (SOC): 4/10/2020. Diagnoses include: Parkinsons Disease (a chronic and progressive movement disorder) and Dysphagia (a condition with difficulty in swallowing food or liquid). Discharge from hospice services on 7/15/22. Most recent recertification period: 5/30/22 through 7/28/22. Orders included for the following: Skilled Nursing twice weekly for nine weeks, Social Worker once monthly for 2 months, home health aides five times a week for eight weeks then four times a week for one week, and chaplain once monthly for two months. "Client coordination Notes" report revealed the following. A note by the Home Health Aide on 7/5/22 states, " (Daughter) asked about a list of agencies to help out when pts care prior to being discharged. Email sent to RNCM (Skilled Nurse Case Manager) and LPN (licensed practical nurse). " 7/8/22 note by LPN states, " Medications reconciled with caregiver ... " 7/11/22 note by LPN states, " Medication reconciled with caregiver and refills ordered this visit. Pt to be discharged from service due to extended prognosis. Competent to administer medications safely to this patient. Medication refills ordered. No further needs this visit. " 7/11/22 note by Social worker (SW) states , " late entry from 7/8/22 ...Husband had questions regarding pt ' s d/c (discharge) this Friday 7/15/22. SW educated husband that pt will d/c off of hospice services on Friday 7/15/22 due to extended prognosis and no longer meeting eligibility for hospice criteria. Husband expressed that pt has a PCP (primary care provider) in the community ...Husband did not identify any other needs at that time. Husband stated his daughter might have some questions for SW. SW provided husband with SW ' s work cell phone number. NOMNC (Notice of Medicare Non-Coverage) with d/c date 7/15/22 to be mail to home address on file. " On call RN from 7/13/22 note states, " Nurse practitioner was out today and ordered an antibiotic ... " additional not from same on call nurse on 7/13/22 states, " Called daughter with an ETA (estimated time of arrival), she informed me that she called Compassus to inform us of a change in her mother ' s condition...daughter declined visit this evening. " LPN note from 7/14/22 states, " Follow up visit with pt regarding change in status ...pt to be discharged on 7/15/22 due to extended prognosis. Daughter primary caregiver expressed concerns regarding HHA (Home Health Aide) services. This LPN will reach out to social services for assistance for this family ... " RN note from 7/15/22 states, " Pt noted with increased involuntary movements. Pain denies at present. Pt due to be discharged due to extended prognosis on 7/15/22 ...Pt has PCP in the community. No further needs at this time. " There was no additional SW notes after the late entry SW note on 7/11 that was for communication with the family on 7/8/22. Notice of Medicare Non-Coverage form reviewed on 7/20/22 at approximately 10:30AM. It states on form " SW talked to spouse about discharge on 7/13/22. NOMNC mailed to spouse ... " This form contains information on " Your right to appeal this decision " and " How to ask for an Immediate Appeal. This form is not yet signed by the patient or representative. There was nothing written on the form that the patient/representative refused to sign the form. During interview conducted on 7/20/22 at approximately 1:30 PM, the administrator confirmed the above findings.
L0684
L0684	40929 Based on review of agency policy, clinical records (CR) and interview with agency clinical director, the agency failed to provide hospice discharge summary including all sections required for one (1) of one (1) clinical records reviewed. (CR # 1) Findings included: Policy reviewed occurred on 7/20/22 at approximately 11:30 AM which revealed the following: The policy titled, " Procedure: Discharge/Transfer/Revocation NOT related to missed Face to Face Evaluation " states, " A hospice may discharge a patient from services in only a few specific circumstances: The patient is deceased, the patient is no longer eligible due to a prognosis of greater than 6 months, the patient has moved out of the hospice ' s service area, the patient or other person in the patient ' s home exhibits behavior which is abusive, disruptive or uncooperative to the extent that delivery of care is seriously impaired or the patient/family refuse to permit a face-to-face assessment for the purpose of recertification as required by statute ...Procedure for discharge due to decertification (no longer eligible for hospice services due to extended prognosis beyond 6 months) ...the IDT is responsible for the ongoing assessment of the patient ' s hospice needs, including determinations about the patient ' s eligibility for services based on the physician ' s assessment about the patient ' s prognosis. At any time the prognosis is determined the be likely greater than 6 months, the IDT should begin discharge planning for decertification of the hospice benefit. It is best practice to ensure discussion and determination about ongoing eligibility at least 2 weeks prior to the recertification due date to ensure continuity of care. The discussion about the patient ' s eligibility for hospice services occurs during the IDT meetings and documentation reflects the ongoing determination by the physician and the IDT about continued eligibility. When it is determined the patient can no longer be certified for hospice services the IDT establishes the discharge plan to ensure safety and continuity of care. Consideration should include but not limited to: Medication needs, community resource needs, access to physician services/care support, transition for the patient back to previous community health providers ...provide a copy of the complete discharge summary to the patient ' s attending physician ...A complete discharge summary includes: discharge summary from the EMR, most recent plan of care, most recent medication list, any physician orders provided in the 2 weeks prior to discharge, including any post-discharge planning...For Medicare beneficiaries complete the Notice of Medicare Non-Coverage and schedule a visit by the nurse or SW to review with the patient/representative not less than 48 hours prior to the planned date of discharge. At a scheduled visit with the patient/representative, provide the Notice of Medicare Non-Coverage (NoMNC). NoMNC requires a signature from the patient/representative indicating only that they received the notification. If the patient/representative will not sign the document, the hospice team member must note this on the form with the specific date and time of the meeting and discussion. " CR #1: Start of Care (SOC): 4/10/2020 Diagnoses include: Parkinsons Disease (a chronic and progressive movement disorder) and Dysphagia (a condition with difficulty in swallowing food or liquid). Discharge from hospice services on 7/15/22. Most recent recertification period: 5/30/22 through 7/28/22. Orders included for the following: Skilled Nursing twice weekly for nine weeks, Social Worker once monthly for 2 months, home health aides five times a week for eight weeks then four times a week for one week, and chaplain once monthly for two months. "Hospice Discharge/Transfer Summary Report" was contained in the file and was addressed to CR#1's community primary care physician. Report contained the following information on the the patient: contact information, demographics, advanced directives, Diagnoses, allergies, medication list, vital sign statistics, disciplines and services provided, goal description. Form also states patient "status: discharged. Discharge reason discharged, revoked or decertified." Form did not give a clear picture or definition of why patient was discharged from hospice. In addition, form does not specify if, when or how this form was sent to the patient's community physican. Interview with clinical director on 7/20/22 at approximately 1:30 PM confirmed the above findings.