Nueva Hospice & Palliative Care, LLC

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group and written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed revealed agency did not ensure that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. CLINICAL RECORD 1: The patient, who resided in an assisted living facility, elected the hospice benefit on 11/06/2024 with a terminal diagnosis of senile degeneration of the brain and a secondary diagnosis of dysphagia. During the Registered Nurse (RN) visit on 05/08/2026, the nurse identified the patient as being at risk for aspiration and documented caregiver education regarding swallowing precautions. The RN documented the presence of a fungating lesion to the left lower back. A physician order dated 04/10/2026 directed wound care to cleanse the wound with wound spray, pat dry, apply nystatin powder, and cover lightly with gauze weekly and as needed if soiled or dislodged. The patient was additionally documented as fully dependent for care and incontinent of bowel and bladder. The plan of care for the benefit periods 03/01/2026–04/29/2026 and 04/30/2026–06/28/2026 included orders for Hospice Aide (HA) visits twice weekly. The Hospice Aide plan of care dated 05/15/2026 identified the patient as alert, confused, forgetful, requiring feeding assistance, and receiving a general diet as tolerated. The Hospice Aide was instructed to “offer food and fluids” at each visit. Although the plan of care documented “safety precautions assigned,” no patient-specific safety precautions were identified. The Hospice Aide plan of care did not include patient-specific instructions related to the patient’s aspiration risk, including feeding precautions and monitoring for signs and symptoms of aspiration. Additionally, the Hospice Aide plan of care did not include instructions regarding observation, care, or reporting related to the patient’s wound. The Hospice Aide visit note dated 05/15/2026 documented that food and fluids were offered in accordance with the plan of care. CLINICAL RECORD 2: The patient, who resided in an assisted living facility, elected the hospice benefit on 08/19/2025 with a terminal diagnosis of sequelae of cerebral infarction and a secondary diagnosis of vascular dementia. Review of the physician’s certification of terminal illness for the benefit period 04/16/2026–06/14/2026 documented advanced disease progression, including advanced vascular neurocognitive impairment, continued deterioration consistent with end-stage neurological disease, loss of meaningful verbal communication, minimal interaction, and increased somnolence. During the Registered Nurse (RN) visit on 05/13/2026, the patient was documented as disoriented, with impaired judgment and both receptive and expressive aphasia, confirming significant cognitive impairment and inability to independently direct care. Review of the plan of care for the benefit period 04/16/2026–06/14/2026 included orders for Hospice Aide (HA) visits weekly. Review of the Hospice Aide Plan of Care (POC) dated 08/01/2025, which remained active at the time of the site visit, instructed the Hospice Aide to provide both a shower and a bed bath at each visit, with the notation, “bed bath as needed if unable to tolerate shower.” The Hospice Aide plan of care did not include patient-specific instructions identifying when a shower versus bed bath should be provided or criteria for determining the patient’s tolerance for care. The instruction required the Hospice Aide to independently assess the patient’s condition and determine the appropriate bathing method for a patient with significant cognitive impairment and inability to communicate needs. During a joint clinical record review and interview conducted on 05/20/2026, the Administrator/Director of Nursing (Personnel Record #1) confirmed that the Hospice Aide Plan of Care (POC) did not include patient-specific instructions regarding wound observation/ care and aspiration precautions during hospice aide visits.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed revealed agency did not ensure hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/19/2025, with Hospice Aide services beginning on 08/22/2025. The plan of care for the benefit period from 04/16/2026 to 06/14/2026 included orders for the HA to see the patient weekly. There was a registered nurse (RN) supervisory visit documented on 04/28/2026, followed by another on 05/13/2026 - 15 days between supervisory visits. CLINICAL RECORD 4: The patient elected the hospice benefit on 07/26/2025, with Hospice Aide services beginning on 07/29/2025. The plan of care for the benefit period from 03/23/2026 to 05/21/2025 included orders for the HA to see the patient twice a week. There was a registered nurse (RN) supervisory visit documented on 04/28/2026, followed by another on 05/13/2026 - 15 days between supervisory visits. During a joint clinical record review and interview conducted on 05/20/2026, the Administrator/Director of Nursing (Personnel Record #1) confirmed that the Hospice Aide supervisory visits for Clinical Records 2 and 4 were not completed within the required 14-day timeframe and acknowledged a 15-day interval between supervisory visits performed by the Registered Nurse.”

“It is required that a hospice ensures that “non-core” services are available and provided directly by the hospice or under arrangement. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by document review and interview with the Administrator which revealed the hospice: Failed to provide Occupational therapy and Speech-language pathology services directly or under arrangement, in a manner consistent with accepted standards of practice {HCDT.13. I.}. The cumulative effect of these deficiencies has resulted in the hospice agency’s inability to ensure the provision of quality hospice care for the condition of participation CFR 418.70: Furnishing of non-core services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that an update of the comprehensive assessment was completed as frequently as the condition of the patient requires and no less frequently than every 15 days. CLINICAL RECORD 13: The patient’s date of election was 03/13/2025. The Comprehensive Assessment was dated 03/13/2025. The skilled nursing visits were completed for routine and wound assessment visits 2-5 times a week by the licensed vocational nurse. The registered nurse visit was completed on 05/10/2025 and again on 06/21/2025. There were 58 days between 03/13/2026 and 05/10/2026, and 42 days between 05/10/2026 and 06/21/2026. The record lacked evidence of an updated comprehensive assessment no less than every 15 days. During a joint clinical record review and interview on 04/10/2026, the Administrator/Director of Nursing confirmed that there were greater than 15 days between the comprehensive and updated comprehensive assessment.”

“It is required that the Interdisciplinary Group (IDG), in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 12 of 14 (86%) clinical records reviewed revealed the organization did not ensure the individualized plan of care was reviewed and documented by the IDG no less frequently than every 15 calendar days. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/19/2025. The Initial Plan of Care was dated 11/19/2025. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 11/19/2025 and 04/10/2026. CLINICAL RECORD 2: The patient elected the hospice benefit on 11/06/2024. The Initial Plan of Care was dated 11/06/2025. The record contained one documented IDG review on 10/02/2025. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 11/06/2024-10/02/2025 and from 10/02/2025-04/10/2026. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/25/2025. The Initial Plan of Care was dated 12/25/2025. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 12/25/2025 and 04/10/2026. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/15/2026. The Initial Plan of Care was dated 01/15/2026. The record contained IDG reviews until 02/19/2026. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 02/19/2026 and 04/10/2026. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/01/2025. The Initial Plan of Care was dated 10/01/2025. The record contained IDG reviews until 02/05/2026. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 02/05/2026 and 04/10/2026. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/03/2025. The Initial Plan of Care was dated 12/03/2025. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 12/03/2025 and 04/10/2026. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/19/2025. The Initial Plan of Care was dated 11/19/2025. The record contained IDG reviews until 01/22/2026. There was no other documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 01/22/2026 and 04/10/2026. CLINICAL RECORD 8: The patient elected the hospice benefit on 01/20/2025. The Initial Plan of Care was dated 01/20/2025. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 01/20/2025 and 04/10/2026. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/21/2025. The Initial Plan of Care was dated 04/21/2025. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 04/21/2025 and 04/10/2026. CLINICAL RECORD 10: The patient elected the hospice benefit on 01/16/2026. The Initial Plan of Care was dated 01/16/2026. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care between 01/16/2026 and 04/10/2026. CLINICAL RECORD 11: The patient elected the hospice benefit 11/12/2025. The patient’s date of discharge was 03/02/2026. The Initial Plan of Care was dated 11/12/2025. There was no documented evidence of an IDG meeting between 11/12/2025 and 03/02/2026 to review, revise, and document the individualized plan of care. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/13/2025. The patient’s date of death was 09/10/2025. The Initial Plan of Care was dated 03/13/2025. There was no documented evidence of an IDG meeting between 03/13/2025 and 09/10/2025 to review, revise, and document the individualized plan of care. During a joint clinical record review and interview on 04/10/2026, the Administrator/Director of Nursing (Personnel Record 1) confirmed that there was no documented evidence of IDG reviewed, revised, and documented the individualized plan of care for the above dates. The Administrator/Director of Nursing reported that they changed to using (name of program) and (name of note) for IDG, starting towards the end of 2025. Each discipline would put a progress note into (name of EMR). Then, during the meeting, the team discusses each patient, the (name of note) transcribes the conversations and then creates a note for each patient. The document that the (name of Notes) creates is one long transcript for all of the patients discussed, and not individual IDG notes. There is no actual IDG Update Note entered into the (name of EMR) that contains all the required items.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. Agency Policy: Hand Hygiene Policy No. 7-009, last revised 07/2025, stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patient... after contact with patient’s intact skin (when taking a pulse, blood pressure or lifting a patient); after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated; when moving from a contaminated body site to a clean body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves.” HOME VISIT 2/CLINICAL RECORD 4: During the home visit on 04/09/2026 with the hospice aide (Personnel Record 8), the hospice aide was observed washing hands with soap and water and donning two pairs of gloves. The hospice aide gathered items for the patient’s bath. During setting up the wash basins with water, the hospice aide removed the outer pair of gloves and donned a new pair. The hospice aide gathered the soaps and raised the bed. The hospice aide changed the outer pair of gloves after washing the hair, washing the hands/arms and feet/legs, performing Pericare, washing the back and buttocks, changing the sheets, rinsing the basins and putting up the soaps, cleaning the over-the-bed table, and removing the trash. The hospice aide did not disinfect their hands between glove changes. During a joint document review and interview on 04/09/2026, the Administrator/Director of Nursing confirmed that the staff did not follow the hand hygiene policy.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with a discharge due to death, the hospice did not ensure that bereavement services were provided to the bereaved. CLINICAL RECORD 13: The patient’s election of the hospice benefit was 03/13/2025 and date of death was 09/10/2025. A review of the clinical record revealed no documented evidence for a bereavement plan of care based on the bereavement risk level. CLINICAL RECORD 14: The patient’s election of the hospice benefit was 03/27/2025 and date of death was 12/02/2025. A review of the clinical record revealed no documented evidence for a bereavement plan of care based on the bereavement risk level. During a joint clinical record review and interview on 04/09/2025, the Administrator/Director of Nursing (Personnel Record 1) agreed that there was no completed individualized bereavement plan of care based on the bereavement risk level. During an interview with the Administrator/Director of Nursing, the bereavement program was discussed. The Administrator/Director of Nursing reported that the bereavement plan of care was developed as needed during the twelve months of bereavement, and that a general plan was not in place for the different bereavement risk levels. The bereavement program lacked documented evidence of an organized program. Upon reviewing the bereavement program, the agency lacked documented evidence of an organized program. During an interview with the Administrator/Director of Nursing, it was discussed that the bereavement program was to be discussed in the next month. The Administrator/Director of Nursing reported that the bereavement plan of care was developed as needed during the twelve months of bereavement, and that a general plan was not in place for the different bereavement risk levels.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed revealed the agency did not ensure that counseling services, including spiritual counseling, were provided based on an assessment of the patient’s and family’s spiritual needs. CLINICAL RECORD 13: The patient’s date of election was 03/13/2025. The Initial Plan of Care documented, “Spiritual Visits: Patient/family request no Spiritual Counselor contact at this time. A Spiritual Assessment dated 03/17/2025 documented, “Chaplain will visit patient/spouse 1-2x month to provide ongoing support.” The record lacked evidence of a physician’s order for a chaplain frequency. The record contained a missed visit note for 05/30/2025 and a spiritual visit note dated 06/13/2025 that stated in part, “Chaplain to continue monthly visits.” The record lacked evidence of chaplain visits for April, July, August, and September of 2025. The patient’s date of death was 09/10/2025. During a joint clinical record review and an interview on 04/10/2026, the Administrator/Director of Nursing confirmed there was no documented evidence that spiritual counseling services were provided during the identified times.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (7%) clinical record reviewed with hospice aide services revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. HOME VISIT 2/CLINICAL RECORD 4: The hospice aide care plan (reviewed during the home visit) on 04/09/2026 with the hospice aide (Personnel Record 8) revealed the task “bed bath as needed if unable to tolerate shower... shower every visit; shampoo tray, and swab/clean mouth.” As the HA was entering the patient’s room, the hospice aide stated that the patient would be receiving a bed bath because of pain. Upon arrival, the patient requested to have a shower, but the hospice aide informed the patient that they would have a bed bath due to the pain. The hospice aide did not provide oral care. There was no documented evidence that the hospice aide notified the registered nurse of changes in the patient’s status and request a change to the plan of care. During a joint clinical record review and interview on 04/09/2026, the Administrator/Director of Nursing (Personnel Record 1) confirmed that the hospice aide lacked notification to the registered nurse of changes to the patient’s status and need of a change in the plan of care.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed for patients receiving aide services revealed that the agency did not ensure that the registered nurse made an on-site supervisory visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/19/2025. Hospice aide services began on 11/21/2025. There was a registered nurse (RN) supervisory visit documented on 02/03/2026 and then on 02/19/2026 (16 days between supervisory visits). CLINICAL RECORD 13: The patient elected the hospice benefit on 03/13/2025. Hospice aide services began on 03/13/2025. A registered nurse made a supervisory visit on 07/09/2025 and 07/28/2025 (19 days between supervisory visits). There were supervisory visits completed on 08/18/2025 and then on 09/10/2025 (23 days between supervisory visits). CLINICAL RECORD 14: The patient elected the hospice benefit on 03/27/2025 and was discharged (death) on 12/02/2025. The hospice aide visit notes dated 06/19/2025, 06/30/2025, and 07/17/2025 indicated that the patient was bed bound and couldn’t take a shower.” The hospice aide reported that the patient was in need of somebody to come out and cut the patient’s fingernails and toenails and requested a podiatrist. The shower task remained on the hospice aide plan of care throughout the hospice stay and there was no documented evidence of a podiatry visit for nail care. The RN supervisory note dated 07/21/2025 documented a request by the patient to change their bath days and time to twice a week in the morning. There was no documented evidence these changes were made. The record lacked documented evidence that the RN ensured services ordered by the hospice Interdisciplinary Group (IDG) met the patient’s needs. During a joint clinical record review and interview on 04/10/2026, the Administrator/Director of Nursing (Personnel Record 1) confirmed that the registered nurse did not make an on-site visit to the patient’s home no less frequently than every 14 days, and ensured services ordered by the hospice Interdisciplinary Group (IDG) met the patient’s needs.”