Accord Hospice of the White Mountains, LLC

“The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that the plan of care identified planned interventions based on problems identified in the initial comprehensive assessment. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/30/2024. During the initial nursing assessment dated 09/30/2024, the nurse documented that the patient had a 20 French 3-way catheter in place due to a history of clots in bladder. Also documented was the frequency of the catheter change every 30 days and an unknown date for when the catheter was last changed or the next change date. There was no documented evidence on the plan of care dated 09/30/2024-12/28/2024 that included foley catheter care interventions or goals . CLINICAL RECORD 16: The patient elected the hospice benefit on 12/05/2024. During the initial nursing assessment dated 12/05/20245 , the nurse documented that the patient had a foley catheter present draining clear, amber urine. There was no documented evidence on the plan of care dated 12/05/2024-03/04/2025 that included foley catheter care interventions or goals. During an interview with the Administrator (Personnel Record 6) and the Director of Nurses (Personnel Record 5) on 10/01/2025 they stated that a performance improvement plan for care plans would be written, and education would be provided to the clinical staff.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed for patients requiring a physician’s recertification of terminal illness revealed that the agency did not ensure that the hospice medical director or physician designee signed the recertification of terminal illness no later than two calendar days after the first day of each benefit period and no more than fifteen days before the next benefit period begins. CLINICAL RECORD 3: The clinical record review lacked evidence that the recertification of terminal illness was signed timely, as evidence by the recertification of terminal illness for benefit period 08/24/2025 to 10/22/2025 was signed on 09/04/2025 (11 days after the benefit period began. CLINICAL RECORD 4: The clinical record review lacked evidence that the recertification of terminal illness was signed timely, as evidence by the recertification of terminal illness for benefit period 08/17/2025 to 10/15/2025 was signed 08/25/2025( 8 days after the benefit period began). During a joint review of the clinical record with the administrator (Personnel record 6) on 10/01/2025 she stated that was unaware of this happening but that she would be reviewing and educating staff on importance of obtaining signed recertification of terminal illness timely.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical record reviewed revealed that the agency did not ensure that the clinical record contained past and current physician orders. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/30/2024. The initial nursing assessment documented that “patient has a 20 French 3 way catheter in place due to history of clots in bladder” and “frequency of change is q 30 days and unknown for last changed and next change date”. There were no physicians orders for the Foley catheter to be changed or maintained in the clinical record for the benefit period 09/30/2024 to 12/28/2024. CLINICAL RECORD 16: The patient elected the hospice benefit on 12/05/2024. The initial nursing assessment documented that “patient has a foley cath present draining clear, amber urine”. “. There were no physicians orders for the Foley catheter to be changed or maintained in the clinical record for benefit period 12/05/2024 to 01/26/2025. During an interview with the Administrator (Personnel Record 6) and the Director of Nurses (Personnel Record 5) on 10/01/2025 they stated that a performance improvement plan would be written up, and education would be provided to the clinical staff.”