Divine Hospice and Palliative Care, LLC

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than five days after the election of hospice services. Agency policy Initial Assessment/Comprehensive Assessment, required in part, “the Hospice IDG, in consultation with the patient’s attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the patient’s election of Hospice care.” Clinical Record 8: The patient elected the Hospice benefit on 03/29/2024. The RN documented on the initial assessment dated 03/29/2024 that the patient is Catholic and was open to Chaplain visits. Review of the clinical record revealed an admission order for the Spiritual Counselor prn (as needed) for spiritual needs. There was no documented evidence in the clinical record that the Spiritual Counselor completed the initial assessment of the patient’s spiritual needs, as part of the initial comprehensive assessment, and there was no documentation in the record that the patient had declined the Spiritual Counselor. During an interview and joint review of the clinical record on 01/23/2025, the Administrator stated that she was unable to find evidence in the clinical record that the family declined the Spiritual Counselor.”

“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. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: The types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed, the agency did not ensure documentation of a bereavement plan of care that included the types of bereavement services to be offered. Agency policy Bereavement Services, required in part, “After a patient death has occurred, the case will be discussed at the next IDG [interdisciplinary group] meeting. Recommendations for bereavement will be made based on the severity of grief and determined by the family member’s consent for further services. Bereavement services must reflect the needs of the bereaved. Unless Bereavement Services have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated... The plan of care will note the kind of bereavement services to be offered and frequency of service delivery.” Clinical Record 12: The patient elected the hospice benefit on 01/17/2024 and the patient’s date of death was 03/18/2024. Clinical record review revealed no documented evidence that bereavement services were initiated or that a bereavement plan of care was developed. During an interview on 01/22/2025, the Bereavement Coordinator stated that she could not locate documentation in the clinical record that reflected the bereavement plan of care, or any activities planned or completed. She stated that she remembered that the family refused bereavement, but there was no documentation in the clinical record.”

“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; 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 document review, clinical record review, and interview. In 4 of 12 (33%) clinical records reviewed, the agency did not ensure the Hospice Aide was supervised by a Registered Nurse who makes an on-site visit no less frequently than every 14 days. Agency policy Hospice Aides, required in part, “Hospice Aides are closely supervised to ensure their competence in providing care. At lease every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aide’s presence.” Clinical Record 1: The patient elected the hospice benefit on 10/02/2022. The plan of care dated 07/23/2024 to 09/20/2024 included an order for hospice aide services three times a week starting on 07/22/2024. Clinical record review revealed hospice aide services were provided as ordered on the plan of care. The RN documented an aide supervisory visit on 08/14/2024 and the next aide supervisory visit was dated 09/10/2024, a total of 27 days and 13 days outstanding. Clinical Record 2: The patient elected the hospice benefit on 07/19/2024. The plan of care dated 10/17/2024 to 01/14/2025 included an order for hospice aide services three times a week starting on 10/16/2024. Clinical record review revealed hospice aide services were provided as ordered on the plan of care. The RN documented an aide supervisory visit on 11/04/2024 and the next aide supervisory visit was dated 11/21/2024, a total of 17 days and 3 days outstanding. The RN documented an aide supervisory visit on 12/18/2024 and the next aide supervisory visit was dated 01/03/2025, a total of 16 days and 2 days outstanding. Clinical Record 3: The patient elected the hospice benefit on 06/05/2024. The plan of care dated 09/03/2024 to 12/01/2024 included an order for hospice aide services three times a week starting on 09/04/2024. Clinical record review revealed hospice aide services were provided as ordered on the plan of care. The RN documented an aide supervisory visit on 12/20/2024 and the next aide supervisory visit was dated 01/07/2025, a total of 18 days and 4 days outstanding. Clinical Record 9: The patient elected the hospice benefit on 06/25/2024. The plan of care dated 09/23/2024 to 12/21/2024 included an order for hospice aide services two times a week starting on 09/23/2024. Clinical record review revealed hospice aide services were provided as ordered on the plan of care. The RN documented an aide supervisory visit on 11/14/2024 and the next aide supervisory visit was dated 12/12/2024, a total of 28 days and 14 days outstanding. During an interview on 01/21/2025, the Administrator stated that they have had a lot of staff changes, but they would do some additional education on the requirements of aide supervision visits.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure documentation of the assessment of the skills and competencies for individuals providing care, as required by agency policy. Agency policy Staff Competency Program, required in part, “Patient care staff will be competency assessed at defined intervals: for each new employee (including contract employees) during orientation.” Personnel Record 8: Certified Nurse Assistant date of hire 07/20/2022. Personnel record review revealed no documented evidence of an initial competency assessment during orientation. During an interview and joint review of the personnel record on 01/21/2025, the Administrator and the Office Manager stated that an initial competency assessment could not be found in the record. They were unsure how it was missed, but they would review their process.”