Elite Hospice

“Based on clinical record review and staff interview, it was determined the Agency failed to ensure a psychosocial assessment and spiritual assessment were completed within 5 days of admission as part of the comprehensive assessment for 1 (#8) of 19 (#1 - #19) clinical records reviewed. This failed practice had the potential to affect all patients on census as a delay in assessment could result in a delay in receiving proper care and services. Findings follow: Review of Clinical Record #8 with a start of care date of 12/21/24 revealed a patient with a diagnosis of Cerebral Infarction. The psychosocial and spiritual assessments were completed on 12/30/24. This was 9 days after admission. On 01/28/25 during a meeting with the administrative staff, the Executive Director stated the admission was pushed through in the computer system on the weekend which wasn’t caught in time to assign the appropriate staff to make these visits.”

“Based on record review and personnel interview, it was determined the Agency failed to ensure routine wound measurements were completed to assess for progress toward goals for 2 (#1 and #15) of 3 (#1, #13, and #15) clinical records reviewed with wound treatments. This failed practice had the potential to affect all patients with wound treatments. Findings follow: Review of Clinical Record #1 with a start of care date of 10/09/24 revealed a patient with a diagnosis of Chronic Kidney Disease (CKD) Stage 4. An order dated 10/10/24 documented the Agency was to measure wounds weekly. There were new areas documented as site #3, #4, and #5 with an onset date of 10/29/24. There were multiple missing measurements for site #5. Review of Clinical Record #15 with a start of care date of 10/30/24 revealed a patient with a diagnosis of Alzheimer’s disease. A pressure wound with an onset date of 11/13/24 did not have any further wound measurements in the patient’s records until her death on 12/19/24. On 01/28/24, during an interview with the Executive Director, there was no further information provided regarding the wound measurements. A Policy and Procedure titled, “Wound Assessment, Documentation, Photography” provided by the Executive Director on 01/28/24 noted “.... Document the following in the medical record...Wound measurements (weekly) including the length, depth, and width of the wound in centimeters...””

“Based on Clinical Record review and staff interview, it was determined the Agency did not ensure the Interdisciplinary Group (IDG) had updated the patients Plan of Care in 2 (#1 and #15) of 3 (#1, #13, and #15) Clinical Records reviewed with Pressure Ulcer orders. This lack of a Plan of Care update had the potential to disrupt patient care coordination in all patients currently receiving Pressure Ulcer treatments. Findings follow: Review of clinical record #1 with a start of care date (SOC) date of 10/09/24, revealed a patient with a diagnosis of Chronic Kidney Disease, stage 4. The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 01/15/24 documented wound care to both heels which included cleaning with wound cleanser and cover with a dressing and entry dated 10/09/24. The wound record report documented wounds #1 and #2 on each heel were identified on 10/09/24. The wound record report documented wounds #3, #4, and #5 were identified on 10/29/24. The document also revealed there were multiple wound order changes since 10/09/24. The most current update on the wound orders were not included on the Plan of Care update report dated 01/15/24, nor did it include the wounds #3, #4, and #5. Review of clinical record #15 with a start of care date of 10/30/24, revealed a patient with a diagnosis of Alzheimer’s disease. The Comprehensive Care Plan Report documented wound care to both feet daily and was added on 10/30/24 and edited 11/13/24. The wound to the coccyx identified on 11/13/24 and the wound to the pre-tibial and lower right leg identified on 12/13/24 were not added to the Plan of Care. On 01/28/25 a Policy and Procedure titled, “Care, Treatment & Services” was provided by the Agency. This policy documented, “.... The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: ... d. Drugs, biologicals and treatments necessary to meet the needs of the patient....””

“Based on clinical record review and staff interview, it was determined the Agency failed to ensure the visits by professional healthcare staff were completed as ordered by the physician and the plan of care for 2 (#3 and #8) of 16 (#1, - #3, #5, #7- #17, and #19) patients who received aide care services. The Agency failed to ensure the physician’s orders for oxygen was followed for 1 (#3) of 3 (#3, #13, and #19) patients who had orders for continuous oxygen. This failed practice had the potential to affect patients on the census that receives aide care services, oxygen. Findings follow: A. Aide Visits Review of Clinical Record # 3 with a start of care date of 11/29/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease. The Hospice Certification and Plan of Care with a certification period of 11/29/24 - 02/26/25 documented Hospice Aides to visit 1 time a week for the first week, then 3 times a week for 12 weeks, then 2 times a week for 1 week. On the week of 12/29/24, it was noted there was a missed aide visit. The coordination notes did not include any documentation as to the reason for this missed visit. Review of Clinical Record #8 with a start of care date of 12/21/24 revealed a patient with a diagnosis of Cerebral Infarction. The Hospice Certification and Plan of Care with a certification period of 12/21/24 - 03/20/25 documented Hospice Aides to visit 2 times a week for 13 weeks. On the week of 12/29/24, it was noted there was a missed visit. The coordination notes did not include any documentation as to the reason for this missed visit On 01/28/25, the Executive Director was informed of the missed visit for #3 and #8 and was unable to find any other information regarding why these visits were missed or to demonstrate the visits did occur. B. Oxygen Review of Clinical Record #3 with a start of care date of 11/29/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease. The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 01/15/25 documented Oxygen at 2 liters continuously on the medication list. The coordination notes dated 1/1/25, 1/2/25, 1/7/25, and 1/9/25 documented the use of oxygen at 4 liters. On 01/28/25, the Executive Director was asked to provide any further information regarding this finding and none was provided.”

“Based on clinical record review and staff interview, it was determined the Agency failed to ensure there was coordination with the patient’s clergy/ church for 2 (#7 and #9) of 19 (#1 - #19) clinical records reviewed. This failed practice had the potential to affect all clients on census in that a lack of coordination could result in the patient’s church members and clergy would not be involved at their usual level with the continued spiritual guidance and comfort needed for the patient during their end of life. Findings follow: Review of Clinical Record # 7 with a start of care date of 12/27/24 revealed a patient with a diagnosis of Alzheimer’s disease. A chaplain visit note dated 12/31/24 documented the patient was spiritual and received spiritual support from her local church, [Name of church]. There was no documentation that the clergy was contacted by the Agency. Review of Clinical Record #9 with a start of care date of 01/08/25 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A chaplain visit note dated 01/13/25 documented the patient was spiritual and has a faith community at [Name of church]. The visit summary documented, “... he has not met his new pastor but hopes to soon...” There was no documentation that the clergy was contacted by the Agency. On 01/28/25 the Executive Director was informed of these findings, offered to provide any further information and none was provided.”