Survey Report for 551755

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	551755	A. BUILDING __________ B. WING ______________	04/27/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
SUPPORTIVE HOSPICE CARE INC	1202 MONTE VISTA AVENUE SUITE #4, UPLAND, CA, 91786
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)
L0520
L0520	41459 The hospice agency failed to ensure the Condition of Participation L 520 418.54: Initial & Comprehensive Assessment of the Patient was in compliance as follows: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were reviewed by the Licensed Vocational Nurse (LVN 1) for 2 of 3 sampled home visit patients (Patients 8 and 9) for evaluation and education of medications in the home. This failure had the possibility to result in Patients 8 and 9 having an adverse reaction to the medications if not taken as ordered. (Refer L 530). The cumulative effect of not providing reconciliation of medications can affect the hospice patient preferences and goals of pain management, symptom control, and adverse drug reactions resulting in harm.
L0530
L0530	41459 Based on observation, interview, and record review, the agency failed to ensure the medication profiles (list of all the patients medications ) were reviewed by LVN 1 for 2 of 3 sampled home visit patients (Patients 8 and 9) for evaluation and education of medications in the home. This failure had the possibility to result in Patients 8 and 9 having an adverse reaction to the medications if not taken as ordered. . Findings: During an observation on April 21, 2021, at 10:01 AM, during a home visit for Patient 8, Licensed Vocational Nurse (LVN 1) did not look at, or use a medication profile list for Patient 8's nursing visit. During an interview on April 21, 2021, at 10:15 AM, with the grandson for Patient 8, he stated the nurse does not use a list to confirm proper use or teaching about medications. During an interview on April 21, 2021, at 12:00 PM, with LVN 1, she stated she did not have a medication list for Patient 8, and did not do any medication teaching during the home visit. During an observation on April 21, 2021, at 11:05 AM, the daughter of Patient 9 gave Patient 9 Herbal Supplement drops under her tongue for the purpose of " leg pain." LVN 1 instructed the daughter to put the Herbal Supplement in food or liquid to mask the taste, and also told the daughter the Herbal Supplement helps with pain, anxiety, and sleeplessness. During an observation on April 21, 2021, at 11:25 AM, during a home visit for Patient 9, LVN 1 did not look at, or use a medication profile for Patient 9's nursing visit. During an interview on April 21, 2021, at 11:30 AM, with LVN 1, LVN 1 stated she did not use the current medication list to verify use or for teaching of current medications. LVN 1 stated there was not an order for the Herbal Supplement, but she did some teaching about it, even before calling the doctor to inform him of use of the Herbal Supplement by the family for Patient 9. During a review of the Agency's policy and procedure titled, Medication Profile, revised April 2019, indicated, "5. During ... hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver ... understand the medication regimen. A. Using the medication profile to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications ..."
L0536
L0536	41459 The hospice agency failed to ensure the Condition of Participation L 536 418.56: IDG, Care Planning and Coordination of Services was in compliance as follows: 1) Based on record review and interview, the agency failed to ensure that the scope and frequency of services are met for 10 of 24 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, and 11) by not providing the needs required for patient and family. (Refer L 547) 2) Based on interview, and record review, the agency failed to ensure care and services were provided in accordance with the plan of care for 10 of 24 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 10, and 11). This failure resulted in the agency not adhering to the physician's order for skilled nursing frequency and duration of visits resulting in possible harm to the patients. (Refer to L 555) The cumulative effect of this practice had the potential to prevent the hospice patient and family members from receiving the services needed in a timely manner.
L0547
L0547	41459 Based on interview and record review, the facility failed to provide visits from hospice staff members as ordered by the physician for 10 of 24 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 10, and 11). This failure had the potential to cause the patients harm due to lack of care. Findings: 1) During a review of the clinical record for Patient 1, Benefit Period (BP - number one a length of time the hospice agency has qualified the patient for hospice care with a terminal diagnosis) is reviewed, dates January 14, 2021 - April 13, 2021. The Plan of Care (POC -Physicians Orders) indicated the frequency for the Skilled Nurse (SN - either a Registered Nurse or Licensed Vocational Nurse - provides assessment and teaching, and reviews medications) visits was three times a week, and Certified Home Health Aide (CHHA - helps with bathing and personal care) visits was three times a week. A review of the visits for Patient 1 indicated: During the week of January 17, 2021, Patient 1 received no SN visits and no CHHA visits. During the week of January 24, 2021, Patient 1 received no SN Visits and no CHHA visits. During the week of January 31, 2021, Patient 1 received one SN visit and no CHHA visits. During the week of February 7, 2021, Patient 1 received one SN visit and no CHHA visits. During the week of February 14, 2021, Patient 1 received no SN visits and no CHHA visits. During the week of February 21, 2021, Patient 1 received one SN visit and no CHHA visits. The last visit completed by any agency staff was on February 22, 2021. For the remainder of the benefit period, February 28, 2021 through April 13, 2021, Patient 1 did not receive any SN or CHHA visits. There was no order received at any time to decrease the number of SN or CHHA visits. During an interview on April 19, 2021, at 3:00 PM, with the Acting Director of Patient Care Services (ADPCS - A RN who is responsible for the oversight of clinical matters in the hospice agency), stated that Patient 1 had only two SN visits for his first benefit period of 90 days, and did not have any CHHA visits. The ADPCS stated the visit frequency should have been decreased. 2) During a review of the clinical record for Patient 2, BP number 12 (February 12, 2021 - April 3, 2021) was reviewed. The POC indicated the frequency for the SN visits was one time a week, and the CHHA visit frequency was three times a week. A review of the visits for Patient 2 indicated: During the week of February 3, 2021, Patient 2 received no SN visits and one CHHA visit. During the week of February 8, 2021, Patient 2 received no SN visits and one CHHA visit. During the week of February 15, 2021, Patient 2 received the ordered number of SN visits, and two CHHA visits. During the week of February 22, 2021, Patient 2 received the ordered number of SN visits, and one CHHA visit. During the week of March 1, 2021, Patient 2 received the ordered number of SN visits, and no CHHA visits. During the week of March 8, 2021, Patient 2 received the ordered number of SN visits, and no CHHA visits. During the week of March 15, 2021, Patient 2 received the ordered number of SN visits, and no CHHA visits. During the week of March 22, 2021, Patient 2 received the ordered number of SN visits, and no CHHA visits. During an interview on April 19, 2021 at 1:00 PM, with the ADPCS, she stated there were missed visits for this BP, but no missed visit reports were filled out, and she was not sure if the Physician was notified of the many missed visits. 3) During a review of the clinical record for Patient 3, BP number one (January 25, 2021 - April 24, 2021) was reviewed. The POC indicated the frequency for the SN was 2 times per week, and the frequency for the CHHA was 5 times per week. A review of the visits for Patient 3 indicated: During the week of January 25, 2021, Patient 3 received three SN visits and four CHHA visits. During the weeks of January 31, 2021 and February 7, 2021 Patient 3 received visits as ordered. During the week of February 14, 2021, Patient 3 received one SN visit, and CHHA visits as ordered. During the weeks of February 21, 2021, February 28, 2021, and March 7, 2021, Patient 3 received visits as ordered. During the week of March 14, 2021, Patient 3 received no SN visits, and the ordered number of CHHA visits. During the week of March 21, 2021, Patient 3 received visits as ordered. During the week of March 28, 2021, Patient 3 received one SN visit and four CHHA visits. During the week of April 4, 2021, Patient 3 received one SN visit and CHHA visits as ordered. During the week of April 11, 2021, Patient 3 received no SN visits, and four CHHA visits. There was no documented evidence of a missed visit report in the clinical record for Patient 3. During a concurrent interview on April 20, 2021, at 4:00 PM, with the ADPCS, she confirmed that there were no supplemental orders changing visit frequencies for the weeks with visit discrepancies, and there were no missed visit reports. The ADPCS stated, "It looks like a lot of visits were missed." 4) During a review of the clinical record for Patient 4, BP period number 17 (March 9, 2021 - May 7, 2021 was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was 3 times per week. A review of the visits for Patient 4 indicated: During the week of March 7, 2021, Patient 4 received no SN visits, and the ordered number of CHHA visits. During the week of March 14, 2021, Patient 4 received two SN visits, and the ordered number of CHHA visits. During the week of March 21, 2021, Patient 4 received two SN visits, and the ordered number of CHHA visits. During the week of March 28, 2021, Patient 4 received the ordered number of SN and CHHA visits. During the week of April 4, 2021, Patient 4 received two SN visits, and the ordered number of CHHA visits. During the week of April 11, 2021, Patient 4 received the ordered number of SN visits, and no CHHA visits. During an interview on April 20, 2021, with the ADPCS, she confirmed the missing or additional visits as listed above for Patient 4, with no physicians order changing the visit frequency. She was unable to locate any missed visit notes or any evidence the physician had been notified regarding the visit discrepancies. 5) During a review of the clinical record for Patient 5, BP number 6 (February 1, 2021 - April 1, 2021) was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was three times per week. A review of the visits for Patient 5 indicated: During the week of February 1, 2021, Patient 5 received no SN visits, and no CHHA visits. During the week of February 7, 2021, Patient 5 received no SN visits, and no CHHA visits. During the week of February 14, 2021, Patient 5 received SN visit as ordered, and one CHHA visit. During the week of February 21, 2021, Patient 5 received no SN visits, and CHHA visits as ordered. During the week of February 28, 2021, Patient 5 received SN visits as ordered, and two CHHA visits. During the week of March 7, 2021, March 14, 2021, Patient 5 received SN and CHHA visits as ordered. During the week of March 21, 2021, Patient 5 received two SN visits, and CHHA visits as ordered. During the week of March 28, 2021, Patient 5 received two SN visits, and CHHA visits as ordered. During a concurrent interview on April 20, 2021, at 11:15 AM with the ADPCS, the ADPCS confirmed the visits that were not made, as listed above, and stated she does not know why there were two weeks where an extra SN visit was made. 6) During a review of the clinical record for Patient 6, BP number 13 (February 25, 2021 - April 25, 2021) was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was three times per week. A review of the visits for Patient 6 indicated: During all weeks Patient 6 received visits from the SN as ordered. During the week of February 21, 2021, Patient 6 received no CHHA visits. During the week of March 7, 2021, Patient 6 received two CHHA visits. During the week of March 14, 2021, Patient 6 received one CHHA visit. During the week of March 21, 2021, Patient 6 received no CHHA visits. During the weeks of March 28, 2021 and April 4, Patient 6 received SN and CHHA visits as ordered. During the week of April 11, 2021, Patient 6 received SN visits as ordered, and two CHHA visits. During a concurrent interview on April 21, 2021, at 1:10 PM, the ADPCS confirmed the missing visits, and that there were no missed visit notes. The ADPCS stated, "I don't know why the CHHA missed so many visits." 7) During a review of the clinical record for Patient 7, BP number two (March 10, 2021 - current date April 21, 2021) was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was three times per week. A review of the visits for Patient 7 indicated: During the week of March 10, 2021, Patient 7 received SN visits as ordered, and four CHHA visits. During the week of March 14, 2021, Patient 7 received no SN visits, and five CHHA visits. During the week of March 21, 2021, Patient 7 received SN visits as ordered and five CHHA visits. During the week of March 28, 2021, Patient 7 received no SN visits and five CHHA visits. During the week of April 4, 2021, Patient 7 received SN visits as ordered and four CHHA visits. During the week of April 11, 2021, Patient 7 received no SN visits, and CHHA visits as ordered. During an interview on April 21, 2021, at 3:15 PM, with the ADPCS, the ADPCS stated she did not know why the CHHA visits were done five times per week for multiple weeks for Patient 7, and that the CHHA visits should have been provided to Patient 7 three times per week per the doctor's order. The ADPCS also stated that she did not know why the SN missed seeing Patient 7 several different weeks. The ADPCS confirmed that there were no changes in frequency orders, and that there were no missed visit reports for Patient 7. 8) During a review of the clinical record for Patient 8, BP number 16 (January 4, 2021 - March 4, 2021) was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was two times per week to start on February 26, 2021 per a new order. A review of the visits for Patient 8 indicated: During all weeks except two, Patient 8 received SN visits as ordered. During the week of January 10, 2021, Patient 8 received no SN visits. During the week of January 31, 2021, Patient 8 received two SN visits. During the week of February 27, 2021, Patient 8 received no CHHA visits. During an interview on April 21, 2021, at 12:00 PM, with the ADPCS, the ADPCS stated she did not know why Patient 8 did not receive any CHHA visits, or why there was no SN visit the week of January 10, 2021, or why there was an extra SN visit the week of January 31, 2021. The ADPCS stated that the number of visits should match the physician's orders. 10) A review of the plan of care summary on April 26, 2021 at 3:00 PM, revealed Patient 10 had diagnoses that included Atherosclerotic Heart Disease without Angina (narrowing of heart arteries without chest pain). Patient 10 had a start of care date of December 11, 2019. The physician's order for Patient 10, dated April 08, 2020, indicated an order to conduct a skilled nursing frequency of visits "1x/week and 2 PRN" (one time a week and two as needed) for symptom management. During a review of Patient 10's electronic medical record, visits were reviewed from February 03, 2021 to April 03, 2021. There were no skilled nursing visits and communication notes on the week of February 07, 2021 to February 13, 2021 and the week of March 07, 2021 to March 13, 2021. During a concurrent interview, and review of Patient 10's electronic medical record with Acting Director of Patient Care Services (ADPCS) on April 27, 2021, at 9:00 AM, ADPCS validated that there were no skilled nursing visits and communication notes on the week of February 07, 2021 to February 13, 2021 and the week of March 07, 2021 to March 13, 2021. The ADPCS stated it was not compliant because the agency did not follow the physician's order of skilled nursing frequency visits. 11) A review of the plan of care summary on April 26, 2021 at 4:00 PM, revealed Patient 11 had diagnoses that included Congestive Heart Failure (heart is unable to pump sufficiently). Patient 11 had a start of care date of October 14, 2018. The physician's order for Patient 11, dated December 07, 2019, indicated an order to conduct a skilled nursing frequency of visits "1-2x/week and 2 PRN" (one to two times a week and two as needed) for COC (change of condition). During a review of Patient 11's electronic medical record, visits were reviewed from January 31, 2021 to March 31, 2021. There were no skilled nursing visits on the week of February 07, 2021 to February 13, 2021, February 21, 2021 to February 27, 2021, February 28, 2021 to March 06, 2021 and March 14, 2021 to March 20, 2021. During a concurrent interview, and review of Patient 11's electronic medical record with Acting Director of Patient Care Services (ADPCS) on April 27, 2021, at 9:15 AM, ADPCS validated that there were no skilled nursing visit on the week of February 07, 2021 to February 13, 2021, February 21, 2021 to February 27, 2021, February 28, 2021 to March 06, 2021 and March 14, 2021 to March 20, 2021. The ADPCS stated it was not compliant because the agency did not follow the physician's order of skilled nursing frequency visit. During a review of the facility's policy and procedure (P&P) titled, "The Plan of Care," revised April 2019, the P&P indicated, "4. The plan of care will identify the patient's needs and services to meet those needs ...It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs ... 12. The written plan of care will contain, but will not be limited to, the following: ... J. Frequency and type of services ... 14. Care provided to the patient will be in accordance with the plan of care." During a review of the facility's policy and procedure (P&P) titled, "Missed Visits," revised April 2019, indicated, "1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained, and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patient's clinical record the following information: 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs and how the patient's needs were met 5. Any other follow up needed 6. Other person(s) that were notified of the missed visit 7. Signature of staff member reporting the information. 3. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. 5. If a patient is routinely refusing visits, the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustment to the plan of care with input from the patient and medical director."
L0555
L0555	41459 Based on interview, and record review, the agency failed to ensure care and services were provided in accordance with the plan of care for 10 of 24 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 10, and 11). This failure resulted in the agency not adhering to the physician's order for skilled nursing frequency and duration of visits resulting in possible harm to the patients. Findings: 1) During a review of the clinical record for Patient 1, Benefit Period (BP - number one a length of time the hospice agency has qualified the patient for hospice care with a terminal diagnosis) is reviewed, dates January 14, 2021 - April 13, 2021. The Plan of Care (POC -Physicians Orders) indicated the frequency for the Skilled Nurse (SN - either a Registered Nurse or Licensed Vocational Nurse - provides assessment and teaching, and reviews medications) visits was three times a week, and Certified Home Health Aide (CHHA - helps with bathing and personal care) visits was three times a week. A review of the visits for Patient 1 indicated: During the week of January 17, 2021, Patient 1 received no SN visits and no CHHA visits. During the week of January 24, 2021, Patient 1 received no SN Visits and no CHHA visits. During the week of January 31, 2021, Patient 1 received one SN visit and no CHHA visits. During the week of February 7, 2021, Patient 1 received one SN visit and no CHHA visits. During the week of February 14, 2021, Patient 1 received no SN visits and no CHHA visits. During the week of February 21, 2021, Patient 1 received one SN visit and no CHHA visits. The last visit completed by any agency staff was on February 22, 2021. For the remainder of the benefit period, February 28, 2021 through April 13, 2021, Patient 1 did not receive any SN or CHHA visits. There was no order received at any time to decrease the number of SN or CHHA visits. During an interview on April 19, 2021, at 3:00 PM, with the Acting Director of Patient Care Services (ADPCS - A RN who is responsible for the oversight of clinical matters in the hospice agency), stated that Patient 1 had only two SN visits for his first benefit period of 90 days, and did not have any CHHA visits. The ADPCS stated the visit frequency should have been decreased. 2) During a review of the clinical record for Patient 2, BP number 12 (February 12, 2021 - April 3, 2021) was reviewed. The POC indicated the frequency for the SN visits was one time a week, and the CHHA visit frequency was three times a week. A review of the visits for Patient 2 indicated: During the week of February 3, 2021, Patient 2 received no SN visits and one CHHA visit. During the week of February 8, 2021, Patient 2 received no SN visits and one CHHA visit. During the week of February 15, 2021, Patient 2 received the ordered number of SN visits, and two CHHA visits. During the week of February 22, 2021, Patient 2 received the ordered number of SN visits, and one CHHA visit. During the week of March 1, 2021, Patient 2 received the ordered number of SN visits, and no CHHA visits. During the week of March 8, 2021, Patient 2 received the ordered number of SN visits, and no CHHA visits. During the week of March 15, 2021, Patient 2 received the ordered number of SN visits, and no CHHA visits. During the week of March 22, 2021, Patient 2 received the ordered number of SN visits, and no CHHA visits. During an interview on April 19, 2021 at 1:00 PM, with the ADPCS, she stated there were missed visits for this BP, but no missed visit reports were filled out, and she was not sure if the Physician was notified of the many missed visits. 3) During a review of the clinical record for Patient 3, BP number one (January 25, 2021 - April 24, 2021) was reviewed. The POC indicated the frequency for the SN was 2 times per week, and the frequency for the CHHA was 5 times per week. A review of the visits for Patient 3 indicated: During the week of January 25, 2021, Patient 3 received three SN visits and four CHHA visits. During the weeks of January 31, 2021 and February 7, 2021 Patient 3 received visits as ordered. During the week of February 14, 2021, Patient 3 received one SN visit, and CHHA visits as ordered. During the weeks of February 21, 2021, February 28, 2021, and March 7, 2021, Patient 3 received visits as ordered. During the week of March 14, 2021, Patient 3 received no SN visits, and the ordered number of CHHA visits. During the week of March 21, 2021, Patient 3 received visits as ordered. During the week of March 28, 2021, Patient 3 received one SN visit and four CHHA visits. During the week of April 4, 2021, Patient 3 received one SN visit and CHHA visits as ordered. During the week of April 11, 2021, Patient 3 received no SN visits, and four CHHA visits. There was no documented evidence of a missed visit report in the clinical record for Patient 3. During a concurrent interview on April 20, 2021, at 4:00 PM, with the ADPCS, she confirmed that there were no supplemental orders changing visit frequencies for the weeks with visit discrepancies, and there were no missed visit reports. The ADPCS stated, "It looks like a lot of visits were missed." 4) During a review of the clinical record for Patient 4, BP period number 17 (March 9, 2021 - May 7, 2021 was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was 3 times per week. A review of the visits for Patient 4 indicated: During the week of March 7, 2021, Patient 4 received no SN visits, and the ordered number of CHHA visits. During the week of March 14, 2021, Patient 4 received two SN visits, and the ordered number of CHHA visits. During the week of March 21, 2021, Patient 4 received two SN visits, and the ordered number of CHHA visits. During the week of March 28, 2021, Patient 4 received the ordered number of SN and CHHA visits. During the week of April 4, 2021, Patient 4 received two SN visits, and the ordered number of CHHA visits. During the week of April 11, 2021, Patient 4 received the ordered number of SN visits, and no CHHA visits. During an interview on April 20, 2021, with the ADPCS, she confirmed the missing or additional visits as listed above for Patient 4, with no physicians order changing the visit frequency. She was unable to locate any missed visit notes or any evidence the physician had been notified regarding the visit discrepancies. 5) During a review of the clinical record for Patient 5, BP number 6 (February 1, 2021 - April 1, 2021) was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was three times per week. A review of the visits for Patient 5 indicated: During the week of February 1, 2021, Patient 5 received no SN visits, and no CHHA visits. During the week of February 7, 2021, Patient 5 received no SN visits, and no CHHA visits. During the week of February 14, 2021, Patient 5 received SN visit as ordered, and one CHHA visit. During the week of February 21, 2021, Patient 5 received no SN visits, and CHHA visits as ordered. During the week of February 28, 2021, Patient 5 received SN visits as ordered, and two CHHA visits. During the week of March 7, 2021, March 14, 2021, Patient 5 received SN and CHHA visits as ordered. During the week of March 21, 2021, Patient 5 received two SN visits, and CHHA visits as ordered. During the week of March 28, 2021, Patient 5 received two SN visits, and CHHA visits as ordered. During a concurrent interview on April 20, 2021, at 11:15 AM with the ADPCS, the ADPCS confirmed the visits that were not made, as listed above, and stated she does not know why there were two weeks where an extra SN visit was made. 6) During a review of the clinical record for Patient 6, BP number 13 (February 25, 2021 - April 25, 2021) was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was three times per week. A review of the visits for Patient 6 indicated: During all weeks Patient 6 received visits from the SN and ordered. During the week of February 21, 2021, Patient 6 received no CHHA visits. During the week of March 7, 2021, Patient 6 received two CHHA visits. During the week of March 14, 2021, Patient 6 received one CHHA visit. During the week of March 21, 2021, Patient 6 received no CHHA visits. During the weeks of March 28, 2021 and April 4, Patient 6 received SN and CHHA visits as ordered. During the week of April 11, 2021, Patient 6 received SN visits as ordered, and two CHHA visits. During a concurrent interview on April 21, 2021, at 1:10 PM, the ADPCS confirmed the missing visits, and that there were no missed visit notes. The ADPCS stated, "I don't know why the CHHA missed so many visits." 7) During a review of the clinical record for Patient 7, BP number two (March 10, 2021 - current date April 21, 2021) was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was three times per week. A review of the visits for Patient 7 indicated: During the week of March 10, 2021, Patient 7 received SN visits as ordered, and four CHHA visits. During the week of March 14, 2021, Patient 7 received no SN visits, and five CHHA visits. During the week of March 21, 2021, Patient 7 received SN visits as ordered and five CHHA visits. During the week of March 28, 2021, Patient 7 received no SN visits and five CHHA visits. During the week of April 4, 2021, Patient 7 received SN visits as ordered and four CHHA visits. During the week of April 11, 2021, Patient 7 received no SN visits, and CHHA visits as ordered. During an interview on April 21, 2021, at 3:15 PM, with the ADPCS, the ADPCS stated she did not know why the CHHA visits were done five times per week for multiple weeks for Patient 7, and that the CHHA visits should have been provided to Patient 7 three times per week per the doctor's order. The ADPCS also stated that she did not know why the SN missed seeing Patient 7 several different weeks. The ADPCS confirmed that there were no changes in frequency orders, and that there were no missed visit reports for Patient 7. 8) During a review of the clinical record for Patient 8, BP number 16 (January 4, 2021 - March 4, 2021) was reviewed. The POC indicated the frequency for the SN was one time per week, and the frequency for the CHHA was two times per week to start on February 26, 2021 per a new order. A review of the visits for Patient 8 indicated: During all weeks except two, Patient 8 received SN visits as ordered. During the week of January 10, 2021, Patient 8 received no SN visits. During the week of January 31, 2021, Patient 8 received two SN visits. During the week of February 27, 2021, Patient 8 received no CHHA visits. During an interview on April 21, 2021, at 12:00 PM, with the ADPCS, the ADPCS stated she did not know why Patient 8 did not receive any CHHA visits, or why there was no SN visit the week of January 10, 2021, or why there was an extra SN visit the week of January 31, 2021. The ADPCS stated that the number of visits should match the physician's orders. 10) A review of the plan of care summary on April 26, 2021 at 3:00 PM, revealed Patient 10 had diagnoses that included Atherosclerotic Heart Disease without Angina (narrowing of heart arteries without chest pain). Patient 10 had a start of care date of December 11, 2019. The physician's order for Patient 10, dated April 08, 2020, indicated an order to conduct a skilled nursing frequency of visits "1x/week and 2 PRN" (one time a week and two as needed) for symptom management. During a review of Patient 10's electronic medical record, visits were reviewed from February 03, 2021 to April 03, 2021. There were no skilled nursing visits and communication notes on the week of February 07, 2021 to February 13, 2021 and the week of March 07, 2021 to March 13, 2021. During a concurrent interview, and review of Patient 10's electronic medical record with Acting Director of Patient Care Services (ADPCS) on April 27, 2021, at 9:00 AM, ADPCS validated that there were no skilled nursing visits and communication notes on the week of February 07, 2021 to February 13, 2021 and the week of March 07, 2021 to March 13, 2021. The ADPCS stated it was not compliant because the agency did not follow the physician's order of skilled nursing frequency visits. 11) A review of the plan of care summary on April 26, 2021 at 4:00 PM, revealed Patient 11 had diagnoses that included Congestive Heart Failure (heart is unable to pump sufficiently). Patient 11 had a start of care date of October 14, 2018. The physician's order for Patient 11, dated December 07, 2019, indicated an order to conduct a skilled nursing frequency of visits "1-2x/week and 2 PRN" (one to two times a week and two as needed) for COC (change of condition). During a review of Patient 11's electronic medical record, visits were reviewed from January 31, 2021 to March 31, 2021. There were no skilled nursing visits on the week of February 07, 2021 to February 13, 2021, February 21, 2021 to February 27, 2021, February 28, 2021 to March 06, 2021 and March 14, 2021 to March 20, 2021. During a concurrent interview, and review of Patient 11's electronic medical record with Acting Director of Patient Care Services (ADPCS) on April 27, 2021, at 9:15 AM, ADPCS validated that there were no skilled nursing visit on the week of February 07, 2021 to February 13, 2021, February 21, 2021 to February 27, 2021, February 28, 2021 to March 06, 2021 and March 14, 2021 to March 20, 2021. The ADPCS stated it was not compliant because thes agency did not follow the physician's order of skilled nursing frequency visit. 10) A review of the plan of care summary on April 26, 2021 at 3:00 PM, revealed Patient 10 had diagnoses that included Atherosclerotic Heart Disease without Angina (narrowing of heart arteries without chest pain). Patient 10 had a start of care date of December 11, 2019. The physician's order for Patient 10, dated April 08, 2020, indicated an order to conduct a skilled nursing frequency of visits "1x/week and 2 PRN" (one time a week and two as needed) for symptom management. During a review of Patient 10's electronic medical record, visits were reviewed from February 03, 2021 to April 03, 2021. There were no skilled nursing visits and communication notes on the week of February 07, 2021 to February 13, 2021 and the week of March 07, 2021 to March 13, 2021. During a concurrent interview, and review of Patient 10's electronic medical record with Acting Director of Patient Care Services (ADPCS) on April 27, 2021, at 9:00 AM, ADPCS validated that there were no skilled nursing visits and communication notes on the week of February 07, 2021 to February 13, 2021 and the week of March 07, 2021 to March 13, 2021. The ADPCS stated it was not compliant because the agency did not follow the physician's order of skilled nursing frequency visits. 11) A review of the plan of care summary on April 26, 2021 at 4:00 PM, revealed Patient 11 had diagnoses that included Congestive Heart Failure (heart is unable to pump sufficiently). Patient 11 had a start of care date of October 14, 2018. The physician's order for Patient 11, dated December 07, 2019, indicated an order to conduct a skilled nursing frequency of visits "1-2x/week and 2 PRN" (one to two times a week and two as needed) for COC (change of condition). During a review of Patient 11's electronic medical record, visits were reviewed from January 31, 2021 to March 31, 2021. There were no skilled nursing visits on the week of February 07, 2021 to February 13, 2021, February 21, 2021 to February 27, 2021, February 28, 2021 to March 06, 2021 and March 14, 2021 to March 20, 2021. During a concurrent interview, and review of Patient 11's electronic medical record with Acting Director of Patient Care Services (ADPCS) on April 27, 2021, at 9:15 AM, ADPCS validated that there were no skilled nursing visit on the week of February 07, 2021 to February 13, 2021, February 21, 2021 to February 27, 2021, February 28, 2021 to March 06, 2021 and March 14, 2021 to March 20, 2021. The ADPCS stated it was not compliant because thes agency did not follow the physician's order of skilled nursing frequency visit. During a review of the facility's policy and procedure (P&P) titled, "The Plan of Care," revised April 2019, the P&P indicated, "4. The plan of care will identify the patient's needs and services to meet those needs ...It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs ... 12. The written plan of care will contain, but will not be limited to, the following: ... J. Frequency and type of services ... 14. Care provided to the patient will be in accordance with the plan of care."
L0559
L0559	41459 The hospice agency failed to ensure the Condition of Participation L559, 418.58: Quality Assessment and Performance Improvement was in compliance as follows: Based on record review and interview, the agency failed to develop and implement an effective ongoing QAPI program involving all hospice services for an agency census of 80 patients when: 1a. The agency did not develop and document a QAPI plan (Refer L 560). 1b. The agency did not form a QAPI committee (a group that meets quarterly to coordinate and evaluate QAPI activities, analyze data, determine problem areas and develop action plans) and QAPI committee meetings were not held. (Refer to L 560). 1c. QAPI committee did not provide a process of continual assessment of a hospices performance with implementation of solutions, assessment of the effectiveness of the solutions, and evaluations to determine how it can even do better. (Refer L 560) 1d. The agency could not demonstrate improvement had been made in any (a particular part or feature) of the agency services it offered. (Refer L 560) 2. Based on record review and interview, the agency failed to develop a QAPI program capable of showing measurable improvement in indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) related to improved palliative outcomes and hospice services for an agency census of 80 patients (Refer L 561) 3. Based on record review and interview, the agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performances that enable the hospice to assess processes of care, hospice services, and operations for an agency census of 80 patients (Refer L 562) 4. Based on record review and interview, the agency failed to use quality indicator data, including patient care, and other relevant data, in the design of its program. Data collection must look beyond patient assessment data to examine all facets of a hospice's operation for an agency census of 80 patients (Refer L 563) 5. Based on record review and interview, the agency failed to collect data for an agency of 80 patients (Refer L 564) 5a. The agency did not monitor the effectiveness and safety of services and quality of care (Refer L 564) 5b. The agency did not identify opportunities, and prioritize for improvement in the QAPI program (Refer L 564) 6. Based on record review and interview, the agency's Governing Body did not approve the frequency and detail of the Quality Assessment and Performance Improvement (QAPI) program's data collection for an agency census of 80 patients (Refer L 565). 7. Based on record review and interview, the agency did not provide performance improvement activities which focus on high risk, high volume, or problem prone areas for an agency census of 80 patients. (Refer L 566) 8. Based on record review and interview, the agency did not consider incidence, prevalence, and severity of problems in high risk, high volume, or problem prone areas for an agency census of 80 patients. (Refer L 567) 9. Based on record review and interview, the agency did not show the effect of palliative outcomes, patient safety, and quality of care for an agency of 80 patients (Refer L 568) 10. Based on record review and interview, the agency did not provide performance improvement activities which track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice for an agency of 80 patients. (Refer L 569) 11. Based on record review and interview, the agency did not provide actions aimed at performance improvement, nor implement a way to measure its success and track performance to ensure that improvements were sustained for an agency of 80 patients. (Refer L 570) 12, Based on record review and interview, the agency failed to develop, implement, and evaluate performance improvement projects ( PIP = a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issue or problems, and intervening for improvements) for an agency census of 80 patients. (Refer L 571) 13. Based on record review and interview, the agency failed to provide the number and scope of distinct performance improvement projects which are to be conducted annually for an agency census of 80 patients: a. The agency did not provide a annual project based on needs of the hospice population and internal organizational need.(Refer L 572) b. The agency did not provide an annual project which reflects the scope, complexity, and past performance of the hospices services and operations. (Refer L 572) 14. Based on record review and interview, the agency failed to document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects for an agency census of 80 patients.(Refer L 573) 15. Based on record review and interview, the agency did not provide a Governing Body which is responsible for ensuring the following: The agency did not provide a ongoing program for quality improvement and patient safety is defined, implemented, maintained, and evaluated annually for an agency census of 80 (Refer L 574) 16. Based on record review and interview the agency did not provide a hospice wide quality assessment and performance improvement which address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness for an agency census of 80. (Refer L 575) 17. Based on record review and interview the agency did not designate one or more individuals, to be responsible for operating the quality assessment and performance improvement program for an agency census of 80. (Refer L 576) a. The agency did not provide a Governing Body responsible for assuring that the QAPI program is working. (Refer L 576) b. The agency did not provide a Governing Body nor appoint individuals who will operate the QAPI program for the hospice. (Refer L 576) The cumulative effect of these systemic practices had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed and for the mismanagement and underutilization of the agency's QAPI program.
L0560
L0560	41459 Based on record review and interview, the agency failed to development and implement an effective ongoing QAPI program involving all hospice services for an agency census of 80 patients. Findings: 1. There was no documented evidence showing a QAPI program was in place since 2020. 2. There were no reports of QAPI activities with results provided to the Governing Body on a quarterly basis. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. A policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospices' performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually.
L0561
L0561	41459 Based on record review and interview, the agency failed to develop a QAPI program capable of showing measureable improvement in indicators (a measureable element of the agency's practice that can be used to assess the quality of care provided) related to improved palliative outcomes and hospice services for an agency census of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. During a review of the policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually. 1. Senior management with Governing Body oversight will: A. Participate in educational activities to increase their level of understanding and ability to implement quality assessment and performance improvement activities. The educational activities may include: seminars, consultations, readings, periodicals, benchmarking, and review of available information from other organizations regarding the occurrence of sentinel events to reduce the risk of similar sentinel events within the organization. B. Set expectations for performance improvement, set priorities and frequency of data collection and manage processes to improve organization performance. 4. Senior management will report the results of QAPI activities to the Governing Body on a quarterly basis. During an interview on April 20, 2021 at 10: 32 AM, Assistant Director of Patient Care Services ADPCS. Stated she does not have anything to do with QAPI program.
L0562
L0562	41459 Based on interview and record review, the agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performances that enable the hospice to assess processes of care, hospice services, and operations for an agency census of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually. B. Set expectations for performance improvement, set priorities and frequency of data collection and manage processes to improve organization performance. C. Adopt a scientific, problem-solving, data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem solving approach will include, minimally: 1. Planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume, problem prone areas and CMS mandatory reporting items. These may include: a. Risk management, such as advance pain events and medication management b. Utilization management c. Quality Control d. Infection control surveillance e. Patient safety program f. Palliative outcomes tracking such as pain control g. Perception of care activities
L0563
L0563	41459 Based on record review and interview, the agency failed to use quality indicator data, including patient care, and other relevant data, in the design of its program. Data collection must look beyond patient assessment data to examine all facets of a hospice's operation for an agency census of 80 patients Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually.
L0564
L0564	41459 Based on record review and interview, the agency failed to collect data for an agency of 80 patients. a. The agency did not monitor the effectiveness and safety of services and quality of care. b. The agency did not identify opportunities, and prioritize for improvement in the QAPI program. This failure had the potential to result in poor quality of care. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually. B. Set expectations for performance improvement, set priorities and frequency of data collection and manage processes to improve organization performance. C. Adopt a scientific, problem-solving, data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem solving approach will include, minimally: 1. Planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume, problem prone areas and CMS mandatory reporting items. These may include: a. Risk management, such as advance pain events and medication management b. Utilization management c. Quality Control d. Infection control surveillance e. Patient safety program f. Palliative outcomes tracking such as pain control g. Perception of care activities
L0565
L0565	41459 Based on record review and interview, the agency's Governing Body did not approve the frequency and detail of the Quality Assessment and Performance Improvement (QAPI) program's data collection for an agency census of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually.
L0566
L0566	41459 Based on record review and interview, the agency did not provide performance improvement activities which focus on high risk, high volume, or problem prone areas for an agency census of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. C. Adopt a scientific, problem-solving, data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include, minimally: 1. Planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume, problem prone areas and CMS mandatory reporting items. These may include: a. Risk management, such as adverse pain events and medication management, b. Utilization management, c. Quality control, d. Infection control surveillance, e. Patient safety program, f. Palliative outcomes tracking such as pain control, g. Perception of care activities. F. Allocate resources for assessing, improving, and communicating the organization's performance by: `1. Assigning hospice personnel to participate in QAPI activities.
L0567
L0567	41459 Based on record review and interview, the agency did not consider incidence, prevalence, and severity of problems in high risk, high volume, or problem prone areas for an agency census of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. C. Adopt a scientific, problem solving, data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem solving approach will include minimally: 1. Planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume, problem prone areas and CMS mandatory reporting items: a. Risk management, such as adverse pain events and medication management, b. Utilization management, c. Quality control, d. Infection control, e. Patient safety program, f. Palliative outcomes tracking such as pain control, g. Perception of care activities. 2. Settings priorities for the improvement and adjusting priorities in response to unusual or urgent event. 4. Implementing improvement on the basis of assessment and comparison data 5. Maintaining achieved improvements 6. Identifying and establishing activities to measure patient outcomes
L0568
L0568	41459 Based on record review and interview, the agency did not show the affect of palliative outcomes, patient safety, and quality of care for an agency of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with QAPI program. During an interview on April 26, 2021 at 11:30 AM, CO, Regional Director of Operations stated that has not been an update of the QAPI program since March 2020. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020 . 1. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. C. Adopt a scientific, problem solving, data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem solving approachs) will include minimally: 1. Planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume, problem prone areas and CMS mandatory reporting items: a. Risk management, such as adverse pain events and medication management, b. Utilization management, c. Quality control, d. Infection control, e. Patient safety program, f. Palliative outcomes tracking such as pain control, g. Perception of care activities. 2. Providing adequate time for hospice personnel to participate in QAPI, such as performance improvement project teams. 3. Creating and maintaining information systems and data management processes to support collecting, managing , and analyzing of data to improve performance 4. Utilizing appropriate statistical technicians to analyze and display data. 5. Provide hospice personnel training in effective approaches and methods of assessment and improvement 6. Assessing the adequacy of human, information, physical, and financial resources allocated to support performance improvement and patient safety 7. Communication of processes that foster the safety and quality of patient care to patients, staff and the community.
L0569
L0569	41459 Based on record review and interview, the agency did not provide performance improvement activities which track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice for an agency of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, Employee MR, Assistant Director of Patient Care Services (ADPCS). Stated she does not have anything to do with QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. 1. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services F. Allocate resources for assessing, improving, and communicating the organization's performance by: `1. Assigning hospice personnel to participate in QAPI activities. 2. Providing adequate time for hospice personnel to participate in QAPI, such as performance improvement project teams, 3. Creating and maintaining information systems and data management processes to support collecting, managing, and analyzing of data to improve performance, 4. Utilizing appropriate statistical technicians to analyze and display data, a. Statistical tools to include: 1. Run charts that display summary and comparison data, 2. Scatter diagrams, 3. Control charts that display variations and trends over time, 4. Histograms, 5. Pareto Charts, 6. Cause-and-effect or fishbone diagrams, 7. Process flowcharts. 5. Provide hospice personnel training in effective approaches and methods of assessment and improvement. 6. Assessing the adequacy of human, information, physical. 7. Communication of processes that foster the safety and quality of patient care to patients, staff and the community.
L0570
L0570	41459 Based on record review and interview, the agency did not provide actions aimed at performance improvement, nor implement a way to measure its success and track performance to ensure that improvements were sustained for an agency of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. G. Analyze and assess the effectiveness of their contributions to improving organization performance, including review of leadership performance against pre-established, objective process criteria. The senior management, also, measure and assess the performance improvement and safety improvement activities. H. Ensure that performance improvement projects are conducted that reflect the following standards: 1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the organization's services and operations, 2. The organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects, 3. That data collection frequency is sufficient to monitor performance improvement projects and high risk areas, 4. The organization will collect data on the following areas at a frequency identified by policy: a. Significant medication errors, b Significant drug reactions, c. Adverse events, d. Patient perception of the quality and safety of care delivered by the organization.
L0571
L0571	41459 Based on record review and interview, the agency failed to develop, implement, and evaluate performance improvement projects ( PIP = a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issue or problems, and intervening for improvements) for an agency census of 80 patients. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. H. Ensure that performance improvement projects are conducted that reflect the following standards: 1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the organization's services and operations, 2. The organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects, 3. That data collection frequency is sufficient to monitor performance improvement projects and high risk areas, 4. The organization will collect data on the following areas at a frequency identified by policy: a. Significant medication errors, b Significant drug reactions, c. Adverse events, d. Patient perception of the quality and safety of care delivered by the organization. 3. Senior Management will ensure that an integrated patient safety program is implemented throughout the organization by: A. Participating in the design and implementation of the infection control program including the annual influenza vaccination program. 1. Sets incremental influenza vaccination goals, 2. Tracks vaccination rates of staff, 3. Annually evaluates reasons given for declining the influenza vaccine, 4. Provides influenza vaccination data annually. B. Participating in educational activities to increase their knowledge. C. Establishing a process for ongoing assessment of the risks for acquisition and transmission of infectious agents. 1. Sets goals for improving compliance with hand hygiene guidelines. D. Establish a process for at least an annual review of the infection control program.
L0572
L0572	41459 Based on record review and interview, the agency failed to provide the number and scope of distinct performance improvement projects which are to be conducted annually for an agency census of 80 patients: a. The agency did not provide a annual project based on needs of the hospice population and internal organizational need. b. The agency did not provide an annual project which reflects the scope, complexity, and past performance of the hospices services and operations. Findings: There was no documented evidence to show a QAPI program was in place since 2020. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services H. Ensure that performance improvement projects are conducted that reflect the following standards: 1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the organization's services and operations. 2. The organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects, 3. That data collection frequency is sufficient to monitor performance improvement projects and high risk areas, 4. The organization will collect data on the following areas at a frequency identified by policy: a. Significant medication errors, b Significant drug reactions, c. Adverse events, d. Patient perception of the quality and safety of care delivered by the organization. 3. Senior Management will ensure that an integrated patient safety program is implemented throughout the organization by: A. Participating in the design and implementation of the infection control program including the annual influenza vaccination program. 1. Sets incremental influenza vaccination goals, 2. Tracks vaccination rates of staff, 3. Annually evaluates reasons given for declining the influenza vaccine, 4. Provides influenza vaccination data annually. B. Participating in educational activities to increase their knowledge. C. Establishing a process for ongoing assessment of the risks for acquisition and transmission of infectious agents. 1. Sets goals for improving compliance with hand hygiene guidelines. D. Establish a process for at least an annual review of the infection control program.
L0573
L0573	41459 Based on record review and interview, the agency failed to document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects for an agency census of 80 patients. Findings: During a review of the QAPI program there was no documented evidence to show any performance projects were being conducted. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (APS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (DROOL) the DROOL stated that there wasn't an update of QAPI due to OVID. The DROOL stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. HD. Ensure that performance improvement projects are conducted that reflect the following standards: 1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the organization's services and operations, 2. The organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects, 3. That data collection frequency is sufficient to monitor performance improvement projects and high risk areas, 4. The organization will collect data on the following areas at a frequency identified by policy: a. Significant medication errors, B Significant drug reactions, C. Adverse events, d. Patient perception of the quality and safety of care delivered by the organization. 3. Senior Management will ensure that an integrated patient safety program is implemented throughout the organization by: A. Participating in the design and implementation of the infection control program including the annual influenza vaccination program. 1. Sets incremental influenza vaccination goals, 2. Tracks vaccination rates of staff, 3. Annually evaluates reasons given for declining the influenza vaccine, 4. Provides influenza vaccination data annually. B. Participating in educational activities to increase their knowledge. C. Establishing a process for ongoing assessment of the risks for acquisition and transmission of infectious agents. 1. Sets goals for improving compliance with hand hygiene guidelines. D. Establish a process for at least an annual review of the infection control program.
L0574
L0574	41459 Based on record review and interview the agency did not provide a Governing Body which is responsible for ensuring the following: a. The agency did not provide a ongoing program for quality improvement and patient safety is defined, implemented, maintained, and evaluated annually for an agency census of 80. Findings: During a review of the QAPI program there was no documented evidence to show the Governing Body was ensuring a QAPI program was in place. During an interview on April 20, 2021 at 10: 32 AM, Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually. H-4. Senior management will report the results of QAPI activities to the Governing Body on a quarterly basis.
L0575
L0575	41459 Based on record review and interview the agency did not provide a hospice wide quality assessment and performance improvement which address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness for an agency census of 80. Findings: During a review of the QAPI program there was no documented evidence to show improvement actions were documented. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually. H-2. Senior management will ensure that an integrated patient safety program is implemented throughout the organization by: E. Report at least annually, to the governing body on system or process failures and actions taken to improve safety (both proactively and in response to actual occurrence) H-4. Senior management will report the results of QAPI activities to the Governing Body on a quarterly basis.
L0576
L0576	41459 Based on record review and interview, the agency did not designate one or more individuals, to be responsible for operating the quality assessment and performance improvement program for an agency census of 80. a. The agency did not provide a Governing Body responsible for assuring that the QAPI program is working. b. The agency did not provide a Governing Body must also appoint individuals who will operate the QAPI program for the hospice. Findings: During a review of the QAPI program there was no documented evidence to show the agency had appointed anyone to monitor the QAPI program. Review of a facility policy titled, "Improving Organizational Performance, revised April 2019, indicated" ... Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance in governance, management, clinical and support activities; to define expectations and priorities of hospice's performance improvement activities; to define the frequency and detail of data collection and to generate the plan and processes hospice will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. All personnel will be active participants in hospice's quality assessment performance improvement (QAPI) activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually. H-2. Senior management will ensure that an integrated patient safety program is implemented throughout the organization by: E. Report at least annually, to the governing body on system or process failures and actions taken to improve safety (both proactively and in response to actual occurrence) H-4. Senior management will report the results of QAPI activities to the Governing Body on a quarterly basis. During an interview on April 20, 2021 at 10: 32 AM, with the Assistant Director of Patient Care Services (ADPCS), she stated she does not have anything to do with the QAPI program. During an interview on April 26, 2021 at 11:30 AM, with the Regional Director of Operations (RDOO) the RDOO stated that there wasn't an update of QAPI due to COVID. The RDOO stated, "Yeah, well", the QAPI program wasn't done since 2020.
L0579
L0579	36093 Based on observation, interview, and record review, the facility failed to insure that infection control techniques were used by Licensed Vocational Nurse (LVN 1) during the home visits for two of two patients, Patient 8 and Patient 9. This failure had the potential to cause harm to the patients by spreading communicable disease from one home to another. Findings: During an observation on April 21, 2021, at 9:45 AM, at the home of Patient 8, LVN 1 entered the home, and set her hospice bag on the couch in the living room without first placing a barrier device between the couch and the bag. When LVN 1 was finished with the visit at 10:00 AM, she picked up the bag, and without cleaning it, left the house. During an interview on April 21, 2021, at 12:00 PM, with LVN 1, LVN 1 stated that she was aware she sat her bag down on a dirty surface without a barrier device. LVN 1 further stated that she was not supposed to do that. During an observation on April 21, 2021, at 10:50 AM, at the home of Patient 9, LVN 1 entered the bedroom of Patient 9, and set her bag on a cloth chair, and her personal folder on the over-bed table, both without a barrier device between the patient's furniture and the equipment brought into the home. During an interview on April 22, 2021, at 11:30 AM, with LVN 1, LVN 1 stated she did not use a barrier device between her bag and the chair of Patient 9, but she should have. LVN 1 further stated that she got nervous when she could not find the barrier device in her bag, so she just set it down. LVN 1 stated that she did not clean the bag when she was finished with the visit. During a review of the facility's policy and procedure (P&P) titled, "Bag Technique," Revised April 2019, the P&P indicated, "5. When the visit is completed ...7. Paper towels/newspapers used as protective barrier for bag placement in the patient's home will be discarded."
L0587
L0587	41459 The hospice agency failed to ensure the Condition of Participation L587 418.64: Core Services was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure that physician signatures were noted on the Certification of Terminal Illness for Patients 6, 7, 14, 15, 16, 17, 18, 19, 20, 21, 22. (Refer to L 590) 2. Based on interview and record review, the agency failed to ensure Medical Social Services were provided in accordance with the plan of care and with agency's "Psychosocial Services Policy" for Patient 10 and Patient 11. This failure resulted for agency not adhering to the physician's order of medical social worker (MSW) frequency visit that may affect the patients' and families' psychosocial health and status. (Refer to L 594) The cumulative effect of insufficient core services had the potential to alter the responsibilities for the palliation and management of the terminal illness and conditions related to the terminal illness.
L0590
L0590	41459 Based on interview and record review, the facility failed to ensure the Certification of Terminal Illness was signed by the physician for 11 of 22 sampled patients (Patient 6, 7, 14, 15, 16, 17, 18, 19, 20, 21, and 22). This failure had the potential to negatively affect the patient's hospice eligibility, which could result in them losing needed hospice care. Findings: During a review of the clinical record for Patient 6, the Certification of Terminal Illness (CTI - a form signed by the physician indicating the patient has six months or less of a life expectancy) was not signed for benefit period number 11, which was to start on October 28, 2020. The certifying physician summary is a word for word duplicate of the Registered Nurse progress summary. During an interview on April 21, 2021, at 1:30 PM, with the Acting Director of Patient Care Services (ADPCS), the ADPCS confirmed that the CTI for the benefit period number 11 for Patient 6 was not signed by the Physician. During a review of the clinical record for Patient 7, the CTI was not signed for benefit period number two, which was to start on March 10, 2021. There is nothing written in the certifying physician summary. During an interview on April 21, 2021, at 3:30 PM, with the ADPCS, she stated that she did not know why the CTI was not completed or signed by the physician. During a record review of the clinical record for Patient 14, the CTI was not signed for benefit period number seven, which was to start on March 27, 2020. There was nothing written in the RN Progress Summary, Face to Face or Certifying Physician Summary. During an interview on April 26, 2021 at 10:35 AM, with the Acting Director of Patient Care Services (ADPCS), the ADPCS stated if there is nothing on the form it appears as if a visit wasn't done. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician, During a record review of the clinical record for Patient 15, the CTI was not signed for initial benefit period, which was to start on September 11, 2020. The physician summary is word for word duplicate to the RN progress summary During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician, During a record review of the clinical record for Patient 16, the CTI was not signed for initial benefit period, which was to start on March 23, 2021 During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 17, the CTI was not signed for initial benefit period, which was to start on March 24, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 18, the CTI was not signed for initial benefit period which was to start on March 29, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 19, the CTI was not signed for initial benefit period which was to start on March 25, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 20, the CTI was not signed for initial benefit period which was started on March 30, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 21, the CTI was not signed for initial benefit period which was started on March 12, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 22, the CTI was not signed for benefit period number ten which was to start on February 24, 2021. The first paragraph of the RN progress Summary is a duplicate word for word for the Physician Summary. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician A review of the agencies policy titled, "Certification of Terminal Illness", policy number: 2-025.1 stated, 1. At the time of admission ot hospice, the hospice Medical Director or the patients attending physician will complete narrative that reflects the patients individual circumstances based on : his/her review of the patients medical record or, if applicable examination of the patient. ( the hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election statement. 4. Both the attending physician and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim 5.A subsequent recertification, at the beginning of each new benefit period may be signed by the attending physician or the hospice Medical Director. At recertification the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period.
L0594
L0594	41459 Medical social services must be provided by a qualified social worker, under the direction of a physician. Social work services must be based on the patient's psychosocial assessment and the patient's and family's needs and acceptance of these services. Based on interview, and record review, the agency failed to ensure Medical Social Services were provided in accordance with the plan of care and with agency's "Psychosocial Services Policy" for Patient 10 and Patient 11. This failure resulted for agency not adhering to the physician's order of medical social worker (MSW) frequency visit that may affect the patients' and families' psychosocial health and status. Findings: A review of the plan of care summary on April 26, 2021 at 3:00 PM, revealed Patient 10 had diagnoses that included Atherosclerotic Heart Disease without Angina (narrowing of heart arteries without chest pain). Patient 10 had a start of care date of December 11, 2019. The physician's order for Patient 10, dated January 30, 2020, indicated an order for medical social work (MSW) visit every month and prn (as needed) for psychosocial support. During a review of Patient 10's electronic medical record, the last MSW visit note was dated on January 09, 2020. No other MSW visit note found after this date. During a concurrent interview, and review of Patient 10's electronic medical record with Acting Director of Patient Care Services (ADPCS) on April 27, 2021, at 9:00 AM, ADPCS validated that the last MSW visit note was dated on January 09, 2020. She stated it's been more than a year that there's no MSW visit. The ADPCS agreed it was not compliant because agency did not follow the physician's order of medical social work visit. A review of the plan of care summary on April 26, 2021 at 4:00 PM, revealed Patient 11 had diagnoses that included Congestive Heart Failure (heart is unable to pump sufficiently). Patient 11 had a start of care date of October 14, 2018. The physician's order for Patient 11, dated December 07, 2019, indicated an order to conduct a medical social work visit (MSW) "1x/month and 1PRN" (one time a month and once as needed). During a review of Patient 11's electronic medical record, the last MSW visit note was dated on June 21, 2019. No other MSW visit note found after this date. On November 12, 2020 a MSW phone call was made and ADPCS confirmed it by reading the note herself. During a concurrent interview, and review of Patient 11's electronic medical record with Acting Director of Patient Care Services (ADPCS) on April 27, 2021, at 9:15 AM, ADPCS validated that the last MSW visit note was dated on June 21, 2019. No other MSW visit note found after this date. On November 12, 2020 a MSW phone call was made and ADPCS confirmed it by reading the note herself. The ADPCS agreed it was not compliant because agency did not follow the physician's order of medical social work visit. On April 27, 2021, at 1:40 PM, a review of the facility's policy and procedure titled, "Psychosocial Services," dated revised on April 2019, the P&P indicated, "Supportive Hospice Care will provide psychosocial services by qualified social workers (MSW, BSW) under the direction of a physician and in accordance with the plan of care. Duties and responsibilities of social workers will be identified in appropriate job descriptions." On April 27, 2021, at 2:00 PM, a review of the facility's job description for "Medical Social Worker/Social Work Associate," dated revised on August 2015, it indicated, essential job functions/responsibilities #3 "Maintains clinical records on all patients referred to social work."
L0603
L0603	41459 The hospice agency failed to ensure Condition of Participation L 603 418.72: Physical, Occupational, and Speech-Language Pathology was in compliance as follows: 1. Based on record review and interview, the agency failed to ensure that physical therapy and occupational therapy assessments were provided as ordered for 2 of 2 patients (Patients 3 and 7) by not providing services as ordered. (Refer L 604) The cumulative effect had the hospice agency ordering rehabilitative services, but the hospice patient never received the rehabilitative service as ordered causing decreasing body movement and safety of the hospice patients.
L0604
L0604	41459 Based on record review and interview, the facility failed to ensure the Physical Therapy (PT) and Occupational Therapy (OT) services ordered by the physician had assessments, orders, and notes in the records for two of two patients (Patient 3) with PT/OT orders. This failure had the potential for Patient 3 to suffer from injury due to safety concerns not documented and communicated to the hospice staff. Findings: During a review of the clinical record for Patient 3, there was a physician's order for PT and OT to evaluate and treat dated January 25, 2021. There were no evaluations or treatment orders from PT or OT in the record. The agency called the contracted PT and OT to ask for notes, and only provided the Certified Occupational Therapy Assistant (COTA) notes dated March 25, 2021, March 26, 2021, and March 30, 2021. The three COTA notes were simple one paragraph narrative notes, the notes were not co-signed by an Occupational Therapist. The agency was unable to provide any assessments, orders, or plans of care for the PT and OT services. During an interview on April 20, 2021, at 4:00 PM, with the Acting Director of Patient Care Services (ADPCS), she stated she does not know when the assessments were completed, she does not know the assignments or the frequency ordered. The agency was unable to produce any other documentation from their contracted PT / OT provider.
L0651
L0651	41459 Based on record review and interview, the agency failed to provide a Governing Body ( or designated persons so functioning) assuming full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement as follows: 1. A qualified administer appointed by and reporting to the governing body is responsible for the day-to day operations of the hospice. 2. The administrator must be a hospice employee and possess education and experience required by the hospice's governing body. Findings: Review of the agency's policy titled, "Governing Body" Policy Number: 4-004.1 stated, "The Governing Body will assume full legal authority and responsibility for the operation of Supportive Hospice Care. The Governing Body of Supportive Hospice Care will serve as the governing authority for the hospice program, which will function according to Supportive Hospice Care's bylaws". 1. The Governing Body will review Supportive Hospice Care's bylaw at least annually. During a record review and interview with the Regional Director of Operations on April 21, 2021 at 9:58 AM, the (RDOO) stated, the Governing Body was not updated due to Covid. When asked about the Governing Body meetings not held since 2019, the RDOO stated, "No, we have not had any meetings for Governing Body since 2019".
L0664
L0664	41459 The hospice agency failed to ensure Condition of Participation L 664, 418.102: Medical Director was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure that the Initial Certification of Terminal Illness assessments were properly reviewed and signed by the Medical Director or Physician Designee for Patients 15, 16, 17, 18, 19, 20, 21. (Refer to L 667) The agency failed to ensure the Recertification of Certification of Terminal Illness assessments were properly reviewed and signed by the Medical Director or Physician Designee for Patients 6, 7, 14, and 22. (Refer to L 668) A cumulative effect of this practice can prevent the hospice patient from having continuity of care.
L0667
L0667	41459 Based on interview and record review, the facility failed to ensure the Initial Certification of Terminal Illness was signed by the physician for 7 of 24 sampled patients (Patient 15, 16, 17, 18, 19, 20, 21). This failure had the potential to negatively affect the patient's hospice eligibility, which could result in them losing needed hospice care. Findings: During a record review of the clinical record for Patient 15, the CTI was not signed for initial benefit period, which was to start on September 11, 2020. The physician summary is word for word duplicate to the RN progress summary. During a record review of the clinical record for Patient 16, the CTI was not signed for initial benefit period, which was to start on March 23, 2021 During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician. During a record review of the clinical record for Patient 17, the CTI was not signed for initial benefit period, which was to start on March 24, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 18, the CTI was not signed for initial benefit period which was to start on March 29, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 19, the CTI was not signed for initial benefit period which was to start on March 25, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 20, the CTI was not signed for initial benefit period which was started on March 30, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During a record review of the clinical record for Patient 21, the CTI was not signed for initial benefit period which was started on March 12, 2021. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician, The initial certification of terminal illness for patients (15, 16, 17, 18, 19, 20, 21) were not signed by a physician. Review of the agencies policy titled, "Certification of Terminal Illness", policy number: 2-025.1 stated, 1. At the time of admission to hospice the hospice Medical Director or the patients attending physician will complete narrative that reflects the patients individual circumstances based on : his;her review of the patients medical record or, if applicable examination of the patient. ( the hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election statement. 4. Both the attending physician and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. A subsequent recertification, at the beginning of each new benefit period may be signed by the attending physician or the hospice Medical Director. At recertification the hospice Medical Director must compose and sign the narrative based on a review of the patients's medical record. A verbal or written certification
L0668
L0668	41459 Based on interview and record review, the facility failed to ensure the Certification of Terminal Illness was signed by the physician for 4 of 24 sampled patients (Patient 6, 7, 14, and 22). This failure had the potential to negatively affect the patient's hospice eligibility, which could result in them losing needed hospice care. Findings: During a review of the clinical record for Patient 6, the Certification of Terminal Illness (CTI - a form signed by the physician indicating the patient has six months or less of a life expectancy) was not signed for benefit period number 11, which was to start on October 28, 2020. The certifying physician summary is a word for word duplicate of the Registered Nurse progress summary. During an interview on April 21, 2021, at 1:30 PM, with the Acting Director of Patient Care Services (ADPCS), the ADPCS confirmed that the CTI for the benefit period number 11 for Patient 6 was not signed by the Physician. During a review of the clinical record for Patient 7, the CTI was not signed for benefit period number two, which was to start on March 10, 2021. There is nothing written in the certifying physician summary. During an interview on April 21, 2021, at 3:30 PM, with the ADPCS, she stated that she did not know why the CTI was not completed or signed by the physician. During a review of the clinical record for Patient 14, The Certification of Terminal Illness was not signed for benefit period number 7, which was to start on March 27, 2020. The whole form for Certification has been left blank. During an interview on April 26, 2021 at 10:35 AM, with the Acting Director of Patient Care Services (ADPCS), the ADPCS stated if there is nothing on the form it appears as if a visit wasn't done. During a review of the clinical record for Patient 22, The Certification of Terminal Illness was not signed for benefit period number 10 which was to start on February 24, 2021. The certifying physician summary is a word for word duplicate of the Registered Nurse progress summary. During an interview on April 21, 2021, at 2:00 PM, with the Regional Director of Operations (RDOO) she stated the CTI form which is labeled Signature on File/Verified by with a typed name is not the signature of the physician. During an interview on April 21, 2021, at 3:30 PM, with the ADPCS, she stated that she did not know why the CTI was not completed or signed by the physician. Review of the agencies policy titled, "Certification of Terminal Illness", policy number: 2-025.1 stated, 4. Both the attending physician and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. A subsequent recertification, at the beginning of each new benefit period may be signed by the attending physician or the hospice Medical Director. At recertification the hospice Medical Director must compose and sign the narrative based on a review of the patients's medical record. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days or two (2)calendar days after the first day of each period. The signed and dated certification must be present prior to billing for each recertification period.
L0670
L0670	41459 The hospice agency failed to ensure the Condition of Participation L 670 418.104: Clinical Records was in compliance as follows: Based on interview and record review, the agency failed to ensure the hospice discharge order and discharge summary were completed for one of 22 sampled patients (Patient 1). This failure resulted in Patient 1 remaining on the active census list, which could have caused a delay in treatment had he attempted to seek medical care. (Refer to L 684) The cumulative effect of this practice had the potential to cause problems in health outcomes, patient safety, and quality of care to go unrecognized.
L0684
L0684	41459 Based on interview and record review, the agency failed to ensure the hospice discharge order and discharge summary were completed for one of 22 sampled patients (Patient 1). This failure resulted in Patient 1 remaining on the active census list, which could have caused a delay in treatment had he attempted to seek medical care. Findings: During a review of the clinical record, the "Plan of Care / Interdisciplinary Group (IDG) Review" dated March 2, 2021, indicated, "IDG performed today with interdisciplinary team. Upon discussion of patient and his non-adherence to treatment goals, DOO states that patient will be discharged for cause from service effective immediately. No further contact or assessment to be conducted by this writer (Registered Nurse) from this day forward." During a review of the clinical record, the "Plan of Care / Interdisciplinary Group (IDG) Review" dated April 14, 2021, indicated, "Patient is no longer at current address and no longer reachable by phone. Patient's sister was notified by MSW that due to his non compliance for his own safety and health care needs and unsafe living situation, hospice will discharge patient from hospice services as of today ..." During a review of the agency active admission list on April 19, 2021, Patient 1 was listed and counted in the agencies active census. During a list of discharges for the past month, Patient 1 was not listed as discharged. During an interview on April 22, 2021, at 3:00 PM, with the Acting Director of Patient Care Services (ADPCS), the ADPCS stated that Patient 1 was discharged on April 14, 2021, and she had written the discharge order herself. When asked why Patient 1 was still on the active census, and counted in the total active patients on April 19, 2021, the ADPCS stated that he stays on the active list until a discharge summary is written. When asked when the discharge summary was written, the ADPCS stated that she had just written it today. When asked why the discharge summary was dated for today, the ADPCS stated that the date of discharge will auto populate on the discharge summary. When asked why Patient 1 was not discharged on March 2, 2021 per the IDG meeting notes written on that day, the ADPCS stated that she did not know. During a review of the agency's policy and procedure (P&P) titled, "Discharge Summary," revised April 2019, the P&P indicated, " ...2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service."
L0690
L0690	41459 Based on interview and record review, the facility failed to ensure that orders for narcotics were entered into the electronic clinical record for Patient 1. This failure had the potential to result in narcotic diversion. Findings: A review of the "Physician's Orders" for Patient 1, dated February 23, 2021, indicated, "start date: February 23, 2021 ... Stop Date: March 10, 2021 ... Norco (a controlled substance, with high risk for addiction and dependence) strength: 5 milligrams, 28 tablets, take one tablet two times daily as needed for pain." This is the only order for narcotics written in Patient 1's record. A review of the Admission Plan of Care (Physician's Orders) indicated no narcotics were ordered. A review of a "nurses note" dated January 26, 2021, indicated, "Placed refill request with pharmacy for opiates." A review of two "nurse's notes," dated February 4, 2021 and February 22, 2021, the nurses notes indicated, "utilizing narcotics." A review of the Registered Nurse (RN) "communication note" dated February 23, 2021, indicated, "This writer is contacted by Director of Operations, to request contact with [Physician Name] to discuss [Patient 1] pain relief plan [Patient 1] is requesting controlled opiate pain relief intervention and Director of Operations would like to accommodate this request. [Patient 1] housing status is community dwelling, and currently there are no safeguards in place for storage or administration of a controlled substance in this environment ... discusses this request with [Physician], and he provides order for Norco ... for 14 days ..." During an interview on April 21, 2021, at 2:17 PM, with the Pharmacist at [Name of Pharmacy], the Pharmacist confirmed that the Pharmacy had delivered narcotics to Patient 1 on three different occasions on the instructions of the agency. Norco was delivered to Patient 1 on January 17, 2021, January 26, 2021, and on February 23, 2021. During a concurrent record review and interview on April 22, 2021, at 1:30 PM, with the Acting Director of Patient Care Services (ADPCS), the ADPCS was able to access the clinical record for Patient 1 during the interview. The ADPCS stated Patient 1 had only had two in-person visits with the Skilled Nurse during his first benefit period January 14, 2021 until April 13, 2021. The DPCS was asked to look through the chart for any narcotic orders. There was only one order on February 23, 2021. The ADPCS confirmed there were no narcotic orders on admission or at any other time. When asked how it was possible for the Pharmacy to deliver narcotics two times, on January 17, 2021, and on January 26, 2021 to Patient 1 without a Physician's order, the ADPCS stated that she didn't know. The agency was unable to provide a policy and procedure for writing physician orders, but the ADPCS stated in lieu of a policy and procedure, "Only licensed nurses can write physician orders, if a licensed nurse gets an order from the physician, the nurse must put the order in the chart immediately for narcotics, but for other things, like change of frequency, they can put it in any time within 24 hours." During a review of the policy and procedure titled, "Home Use and Disposal of Controlled Substances", Dated , April 2019, the policy indicated under procedure. " 1) Controlled substances will be distributed directly to the patient or his/her representative. The interdisciplinary group will be responsible for monitoring the amount of drug used and the length of time between renewals."
L0795
L0795	41459 Based on record review and interview, the agency failed to obtain criminal background checks on employees who have direct patient contact and/or access to patient records for 5 of 13 personnel files reviewed Findings: The agencies policy titled "Selection Hiring of Personnel", policy number 1-004.2 stated 15. All new personnel will be on a probationary status for three (3) months from the date of hire unless otherwise specified. During an interview on April 20, 2021 at 9:30 AM the Office Manager (OM) stated she does not do any of the background checks, the RDOO does all the background checks on all new hires. During an interview on April 21, 2021 at 2:53 PM the Regional Director of Operations (RDOO) stated she does background checks as soon as someone is hired. During a review of the background checks with the RDOO the background checks indicated they were completed three or more months after hire. The RDOO stated, they must have been missed.
L0796
L0796	41459 Based on record review and interview, the agency failed to obtain criminal background checks in accordance with State requirements.The agency did not provide crimminal background checks within a 3 month period of time of the date of employement for all states that the individual lived or worked in the past 3 years for 5 of 13 personnel records reviewed. findings: The agencies policy titled "Selection/Hiring of Personnel", policy number: 1-004.1 stated "2. A criminal background check will be obtained for positions required by law, regulation or organizational policy". During an interview on April 20, 2021 at 9:30 AM, the Office Manager (OM) stated she does not do any of the background checks, the RDOO does all the background checks on all new hires. During an interview on April 21, 2021 at 2:53 PM, the Regional Director of Operations (RDOO) stated she does background checks as soon as someone is hired. During a review of the background checks with the RDOO background checks indicated they were completed three or more months after hire. The RDOO stated, they must have been missed.