Lavender Hospice

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by clinical record reviews, document reviews, and interviews with the Administrator/Medical Director which revealed the hospice: Failed to ensure that hospice care and services provided to patients and families followed an individualized plan of care in 14 of 14 (100%) clinical records reviewed [HCPC.19.I/L543]; Failed to ensure that the plan of care documented planned interventions based on problems identified in the initial and updated comprehensive assessments in 14 of 14 (100%) clinical records reviewed [HCPC.21.I/L545]; Failed to ensure the plan of care included drugs and treatments necessary to meet the patient needs in 14 of 14 (100%) clinical records reviewed [HCPC.21.I/L549]; and Failed to ensure that the Interdisciplinary Group reviewed, revised, and documented the individualized care plan as required, but no less frequently than every 15 days in 14 of 14 (100%) clinical records reviewed [HCPC.21.I/L552]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interviews with the Volunteer Coordinator and Administrator, which revealed the hospice: Failed to provide day-to-day administrative or direct patient services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff [HSLG.7.I/L647]. The cumulative effect of these deficiencies has resulted in the hospice agency’s inability to provide quality care for the Condition of Participation CFR 418.76, Volunteers. The collective deficient practice illustrated not having a process to ensure the provision of volunteer services to all patients.”

“It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); The patient or patient representative if any of them so desire; and The primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed, it was revealed that the agency did not ensure that hospice care and services provided to patients and families per the individualized plan of care established by the Interdisciplinary Group (IDG). CLINICAL RECORD 1: The patient elected the hospice benefit on 01/16/2024. A comprehensive nursing assessment dated 01/16/2024 was documented as performed. The record lacked evidence of an individualized Plan of Care (POC) or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/02/2024. A comprehensive nursing assessment dated 04/02/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/03/2024. A comprehensive nursing assessment dated 05/03/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/11/2024. A comprehensive nursing assessment dated 10/11/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/13/2024. A comprehensive nursing assessment dated 03/13/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/26/2023. A comprehensive nursing assessment dated 09/26/2023 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/23/2024. A comprehensive nursing assessment dated 01/23/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/09/2023. A comprehensive nursing assessment dated 08/09/2023 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/12/2024. A comprehensive nursing assessment dated 07/12/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/27/2024. A comprehensive nursing assessment dated 02/27/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary care giver. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/17/2024. A comprehensive nursing assessment dated 01/17/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/10/2024. A comprehensive nursing assessment dated 04/10/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 13: The patient elected the hospice benefit on 05/24/2024. A comprehensive nursing assessment dated 05/24/2024 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/13/2023. A comprehensive nursing assessment dated 01/13/2023 was documented as performed. The record lacked evidence of an individualized plan of care or any updates to a plan of care. There was no evidence that care and services were provided in accordance with an individualized POC or in collaboration with the hospice IDG, an attending physician (if any), the patient/patient representative, or the primary caregiver. During an interview with the administrator/Medical Director on 01/16/2025, she stated that she did not realize that the Plan of Cares was not being generated in the EMR but was calling the EMR for technical support.”

“It is required that each patient’s individualized written plan of care: Reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical record review revealed the agency did not ensure that each patient had an individualized written plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/16/2024. A comprehensive nursing assessment dated 01/16/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/02/2024. A comprehensive nursing assessment dated 04/02/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/03/2024. A comprehensive nursing assessment dated 05/03/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/11/2024. A comprehensive nursing assessment dated 10/11/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/13/2024. A comprehensive nursing assessment dated 03/13/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/26/2023. A comprehensive nursing assessment dated 09/26/2023 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/23/2024. A comprehensive nursing assessment dated 01/23/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/09/2023. A comprehensive nursing assessment dated 08/09/2023 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/12/2024. A comprehensive nursing assessment dated 07/12/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/27/2024. A comprehensive nursing assessment dated 02/27/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/17/2024. A comprehensive nursing assessment dated 01/17/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/10/2024. A comprehensive nursing assessment dated 04/10/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 13: The patient elected the hospice benefit on 05/24/2024. A comprehensive nursing assessment dated 05/24/2024 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/13/2023. A comprehensive nursing assessment dated 01/13/2023 was documented. The record lacked evidence of an initial Plan of Care or an updated Plan of Care that included all services necessary for the palliation and management of the terminal illness and related conditions. During an interview with the administrator/Medical Director on 01/16/2025, she stated that she did not realize that the Plans of Care was not being generated in the EMR but was calling the EMR for technical support.”

“It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are identified in the plan of care and provided to a patient while under the care of the hospice. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical record review revealed the agency did not ensure that drugs and biologicals related to the palliation and management of the terminal illness and related conditions were identified in the plan of care and provided to the patient while under the care of the hospice. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/16/2024. A comprehensive nursing assessment dated 01/16/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/02/2024. A comprehensive nursing assessment dated 04/02/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/03/2024. A comprehensive nursing assessment dated 05/03/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/11/2024. A comprehensive nursing assessment dated 10/11/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/13/2024. A comprehensive nursing assessment dated 03/13/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/26/2023. A comprehensive nursing assessment dated 09/26/2023. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/23/2024. A comprehensive nursing assessment dated 01/23/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/09/2023. A comprehensive nursing assessment dated 08/09/2023. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/12/2024. A comprehensive nursing assessment dated 07/12/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/27/2024. A comprehensive nursing assessment dated 02/27/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/17/2024. A comprehensive nursing assessment dated 01/17/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/10/2024. A comprehensive nursing assessment dated 04/10/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 13: The patient elected the hospice benefit on 05/24/2024. A comprehensive nursing assessment dated 05/24/2024. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/13/2023. A comprehensive nursing assessment dated 01/13/2023. The clinical record review did not contain evidence that a plan of care identifying the drugs and biologicals related to the palliation and management of the terminal illness and related conditions was in the care plan and provided to the patient while under hospice care. During an interview with the administrator/Medical Director on 01/16/2025, she stated that she did not realize that the Plan of Care was not being generated in the EMR but was calling the EMR for technical support.”

“It is required that the Interdisciplinary Group, 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. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed, it was revealed that the agency did not ensure that the Interdisciplinary Group reviewed, revised, and documented the individualized care plan as required, but no less frequently than every 15 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/16/2024. A comprehensive nursing assessment dated 01/16/2024 was documented as performed. The record lacked evidence of an initial Plan of Care or any updated Plan of Care being generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition but no less frequently than every 15 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/02/2024. During the record review, a comprehensive nursing assessment dated 04/02/2024 was documented. However, the record lacked evidence of an initial Plan of Care or any updated Plan of Care was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/03/2024. A comprehensive nursing assessment dated 05/03/2024 was documented during the record review. The record lacked evidence of an initial Plan of Care or any updated Plan of Care being generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition but no less frequently than every 15 days. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/11/2024. A comprehensive nursing assessment dated 10/11/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or any updated Plan of Care was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/13/2024. A comprehensive nursing assessment dated 03/13/2024 was documented during the record review. The record lacked evidence of an initial Plan of Care or any updated Plan of Care was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/26/2023. A comprehensive nursing assessment dated 09/26/2023 was documented during the record review. The record lacked evidence of an initial Plan of Care or any updated Plan of Care was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/23/2024. A comprehensive nursing assessment dated 01/23/2024 was documented as performed during the record review. was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/09/2023. A comprehensive nursing assessment dated 08/09/2023 was documented as performed during the record review. was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/12/2024. A comprehensive nursing assessment dated 07/12/2024 was documented as performed during the record review. was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/27/2024. A comprehensive nursing assessment dated 02/27/2024 was documented as performed during the record review. was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/17/2024. A comprehensive nursing assessment dated 01/17/2024 was documented as performed during the record review. was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/10/2024. A comprehensive nursing assessment dated 04/10/2024 was documented as performed during the record review. was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 13: The patient elected the hospice benefit on 05/24/2024. A comprehensive nursing assessment dated 05/24/2024 was documented as performed during the record review. was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/13/2023. A comprehensive nursing assessment dated 01/13/2023 was documented as performed during the record review. was generated. No Plan of Care was present for the Interdisciplinary Group to review, revise, and document the individualized care plan with changes in the patient’s condition, but no less frequently than every 15 days. During an interview with the Administrator/Medical Director on 01/16/2025, she stated that she did not realize that the Plan of Cares was not being generated in the electronic medical record (EMR) but was calling the EMR for technical support.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical records review revealed the agency did not ensure that the nursing care was provided under the supervision of a registered nurse. Document 4: The agency policy titled Nursing Services states in part “The RN makes a minimum 30-day supervisory home visit and documents that the LPN is routinely providing nursing services in accordance with the patient’s plan of care and the LPN’s scope of practice.” CLINICAL RECORD 4: The patient elected the Hospice benefit on 03/13/2024. The clinical record review for benefit period 10/11/2024 to 01/09/2025 lacked evidence that the LPN was supervised by an RN at least every 30 days. LPN visits were made on 10/11/2024, 10/13/2024, 10/18/2024, 10/20/2024, 10/24/2024, 11/01/2024,11/04/2024, 11/12/2024, 11/19/2024, 11/21/2024, 11/28/2024, 12/04/2024, 12/06/2024, and 12/24/2024. The first RN supervisory visit was documented on 11/15/2024 (35 days from the 10/11/2024 LPN visit). CLINICAL RECORD 8: The patient elected the Hospice benefit on 08/09/2023. The clinical record review for the benefit period 09/02/2024 to 10/31/2024 lacked evidence that the LPN was supervised by an RN at least every 30 days. An LPN visit was documented on 10/24/2024. An RN supervisory visit for the LVN was not documented for this benefit period. CLINICAL RECORD 11: The patient elected the Hospice benefit on 01/17/2024. Clinical record review for the benefit period 01/17/2024 to 04/15/2025 lacked evidence that the LPN was supervised by an RN at least every 30 days. LPN visits were made on 01/17/2024, 01/23/2024, 01/30/2024, 02/13/2024, 02/20/2024, 02/21/2024, 02/22/2024, 02/23/2024, 02/24/2024, and 02/25/2024. An RN supervisory visit for the LVN was not documented for this benefit period. During a joint record review with the consultant on 01/16/2024 she stated that she did not know why LPN supervisory visits by the RN were not completed and documented.”

“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 clinical record review, document review, and interview. In 11 of 12 (92%) clinical records reviewed, in which hospice aide services were accepted, it was revealed the agency did not ensure the hospice aides were supervised by a registered nurse who makes an on-site visit no less frequently than every 14 days. Agency policy, Hospice Aide Supervision, stated in part, “A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient’s need. The hospice aide does not have to be present during this visit.” CLINICAL RECORD 2: Clinical record reviewed for the benefit period 09/29/2024 to 11/27/2024. Patient had hospice aide visits documented on 10/01/2024, 10/04/2024, 10/08/2024, 10/11/2024, 10/15/2024, 10/18/2024, 10/21/2024, 10/24/2024, 11/05/2024, 11/08/2024, 11/11/2024, 11/18/2024, 11/21/2024, and 11/25/2024. The first documented Aide supervisory visit was on 11/14/2024, which was 45 days from the first aide visit (10/01/2024). CLINICAL RECORD 3: Clinical record review for the benefit period 10/30/2024 to 12/28/2024. Patient had hospice aide visits documented on 11/01/2024, 11/05/2024, 11/08/2024, 11/12/2024, 11/15/2024, 11/19/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/29/2024,12/02/2024, 12/04/2024, 12/06/2024, 12/09/2024, 12/11/2024, 12/13/2024, 12/16/2024, 12/18/2024, 12/20/2024, 12/23/2024, 12/26/2024, and 12/27/2024. An Aide supervisory visit was documented on 11/11/204 and the next one was documented on 12/09/2024, which was 28 days between supervisory visits. CLINICAL RECORD 4: Clinical record review for benefit period 10/11/2024 to 01/08/2025. Patient had hospice aide visits documented on 10/15/2024, 10/18/2024, 10/22/2024, 10/25/2024, 10/29/2024, 11/01/2024, 11/05/2024, 11/08/2024, 11/12/2024, 11/15/2024, 11/19/2024, 11/22/2024, 11/26/2024, 11/29/2024, 12/03/2024, 12/06/2024, 12/10/2024, 12/13/2024, 12/17/2024, 12/20/2024, 12/24/2024, 12/27/2024 and 01/03/2025. The first documented Aide supervisory visit was on 11/15/2024, which was 32 days from the first aide visit (10/15/2024). CLINICAL RECORD 5: Clinical record review for benefit period 11/08/2024 to 01/06/2025. Patient had hospice aide visits documented on 11/08/2024, 11/11/2024, 11/21/2024, 11/25/2024, 11/29/2024, 12/02/2024, 12/05/2024, 12/09/2024, 12/12/2024, 12/16/2024, 12/19/2024, 12/23/2024, 12/26/2024, 12/30/2024, and 01/02/2024. The documentation revealed a 15-day gap between supervisory visits; 12/09/2024 and 12/24/2024. CLINICAL RECORD 6: Clinical record review for the benefit period 05/23/2024 to 07/21/2024. Patient had hospice aide visits documented on 05/23/2024, 05/27/2024, 05/30/2024, 06/03/2024, 06/13/2024, 06/18/2024, 06/24/2024, 06/27/2024, 07/01/2024, 07/08/2024, 07/11/2024, 07/15/2024, and 07/17/2024. An Aide supervisory visit was documented on 06/03/2024; no other aide supervisory visit was documented for the remainder of the benefit period, which was 48 days. CLINICAL RECORD 8: Clinical record review for the benefit period 09/02/2024 to 10/31/2024. The patient had hospice aide visits documented on 09/06/2024, 09/24/2024, 09/27/2024, 10/01/2024, 10/03/2024, 10/08/2024, 10/10/2024, 10/15/2024, 10/17/2024, 10/22/2024, 10/24/2024, 10/29/2024, and 10/31/2024. No aide supervisory visits were noted in the clinical record. CLINICAL RECORD 9: Clinical record review for the benefit period 11/09/2024 to 01/07/2025. Patient had hospice aide visits documented on 11/12/2024, 11/19/2024, 11/22/2024, 11/25/2024, 11/27/2024, 12/03/2024, 12/06/2024, 12/09/2024, 12/13/2024, 12/16/2024, 12/19/2024, 12/24/2024, 12/26/2024, 12/30/2024, and 01/02/2024. Aide An Aide supervisory visit was documented 11/24/2024 with the next one documented on 12/09/2024, which was 15 days, the next one was documented on 12/24/2024, which was 15 days. CLINICAL RECORD 10: Clinical record review for benefit period 10/24/2024 to 12/22/2024. Patient had hospice aide visits documented on 10/24/2024, 10/28/2024, 10/31/2024, 11/04/2024, 11/11/2024, 11/14/2024, 11/17/2024, 11/18/2024, 11/21/2024, 11/25/2024, 11/27/2024, 12/02/2024, 12/05/2024, 12/09/2024, 12/12/2024, 12/16/2024, and 12/19/2024. Aide supervisory visits were documented on 10/27/2024 and 11/13/2024, which was a 17-day gap, and 11/26/2024 to 12/13/2024, which was 17 days. CLINICAL RECORD 11: Clinical record review for the benefit period 01/17/2024 to 04/15/2024. The patient had hospice aide visits documented on 01/19/2024, 01/23/2024, 01/26/2024, 01/30/2024, 02/02/2024, 02/06/2024, 02/09/2024, 02/13/2024, 02/15/2024, 02/16/2024, 02/17/2024, 02/19/2024, 02/20/2024, 02/21/2024, 02/22/2024, 02/23/2024, and 02/24/2024. No aide supervisory visits were noted in the clinical record. CLINICAL RECORD 12: Clinical record review for the benefit period 04/10/2024 to 07/08/2024. The patient had hospice aide visits on 04/15/2024, 04/18/2024, 04/22/2024, 04/25/2024, 04/29/2024, 05/02/2024, 05/06/2024, 05/09/2024, 05/13/2024, 05/16/2024, 05/20/2024, 05/23/2024, 05/27/2024, 05/30/2024, 06/03/2024, 06/10/2024, 06/13/2024, 06/24/2024, 06/27/2024, 02/01/2024, and 02/03/2024. No aide supervisory visits were noted in the clinical record. CLINICAL RECORD 13: Clinical record review for the benefit period 07/19/2024 to 10/16/2024. The patient received aide services as ordered. Aide supervisory visits by the registered nurse were documented on 07/30/2024 and then on 08/23/2024 which was 24 days; the next supervisory visit was documented on 09/18/2024 which was 26 days. During an interview with the Administrator/Medical Director and the consultant on 01/16/2025, they stated that the clinical staff would be educated regarding aide supervisory visits.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. During a review of the volunteer program, the documentation lacked evidence of day-to-day administrative or direct patient care services at a minimum of 5% of the total patient care hours of all paid hospice employees. The volunteer program had evidence of recruitment efforts but none for retention. During an interview with the Volunteer Coordinator, on 01/16/2025, she stated that they did not have any current volunteers. When asked how the needs of the patient were being met if a volunteer was requested, she stated that she would volunteer after hours and see the patient herself. The Volunteer Coordinator’s file (Personnel Record 4) was reviewed and lacked documented evidence of volunteer and volunteer coordinator job descriptions, volunteer training documentation, and volunteer competency. During an interview with the administrator/Medical Director on 01/16/2025, she stated that they currently do not have any volunteers but are actively seeking them and have a performance improvement plan in place. During a review of the volunteer program, the documentation lacked evidence of day-to-day administrative or direct patient care services at a minimum of 5% of the total patient care hours of all paid hospice employees.”

“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, interview and personnel record review. In 6 of 6 (100%) personnel records reviewed revealed that the agency did not ensure that the skills and competencies of all individuals providing care were assessed. Document 3: The agency policy titled Competency Assessment stated in part that “Competency assessment occurs during the orientation period, annually, and as needed, when adverse patient outcomes are directly related to an individual’s performance.” Personnel Record 1: The Registered Nurse was hired on 10/12/2023. The personnel record review lacked evidence of an initial competency assessment performed during the orientation period. Personnel Record 2: The Certified Nurse Aide was hired on 10/29/2023. The personnel record review lacked evidence of an initial competency assessment performed during the orientation period. Personnel Record 3: The Master Social Worker was hired on 02/12/2024. The personnel record review lacked evidence of an initial competency assessment performed during the orientation period. The competency assessment present in the personnel record was dated 12/26/2023, prior to the date of hire. Personnel Record 4: The Chaplain/Bereavement Coordinator/Volunteer Coordinator was hired on 02/06/2018. A competency assessment was present in the personnel record dated 03/06/2024 for the spiritual counselor. There were no annual competencies present for the Bereavement Coordinator position or the Volunteer Coordinator position. Personnel Record 5: The Medical Director/Assessment was hired on 02/22/2018. The personnel record review lacked evidence of annual competency assessments. Personnel Record 6: The Baccalaureate Social Worker was hired on 12/22/2023. The personnel record review lacked evidence of an initial competency assessment performed during the orientation period During an interview with the Medical Director/Administrator/Owner she stated that she was unaware that the competencies had not been completed, however they just had a change in leadership and would be addressing this issue.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical record review revealed the agency did not ensure the patient’s clinical record includes the initial plan of care and updated plans of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/16/2024. A comprehensive nursing assessment dated 01/16/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/02/2024. A comprehensive nursing assessment dated 04/02/2024 was documented during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/03/2024. A comprehensive nursing assessment dated 05/03/2024 was documented during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/11/2024. A comprehensive nursing assessment dated 10/11/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/13/2024. A comprehensive nursing assessment dated 03/13/2024 was documented during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/26/2023. A comprehensive nursing assessment dated 09/26/2023 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/23/2024. A comprehensive nursing assessment dated 01/23/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/09/2023. A comprehensive nursing assessment dated 08/09/2023 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/12/2024. A comprehensive nursing assessment dated 07/12/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/27/2024. A comprehensive nursing assessment dated 02/27/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/17/2024. A comprehensive nursing assessment dated 01/17/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/10/2024. A comprehensive nursing assessment dated 04/10/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 13: The patient elected the hospice benefit on 05/24/2024. A comprehensive nursing assessment dated 05/24/2024 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/13/2023. A comprehensive nursing assessment dated 01/13/2023 was documented as performed during the record review. The record lacked evidence of an initial Plan of Care or of an updated Plan of Care. During an interview with the administrator/Medical Director on 01/16/2025, she stated that she did not realize that the Plan of Cares was not being generated in the EMR but was calling the EMR for technical support.”

“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 9 of 12 (75%) clinical records reviewed, in which a recertification of terminal illness was required, it was revealed that the agency did not ensure that the recertification was completed no more than fifteen days before the next benefit period. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/16/2024. A clinical record review revealed evidence that the Medical Director signed the Recertification of Terminal Illness on 10/17/2024, 25 days before the start of the benefit period, effective 11/11/2024 to 01/09/2025. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/02/2024. A clinical record review revealed evidence that the Medical Director signed the Recertification of Terminal Illness (CTI) on 09/05/2024, 24 days before the start of the benefit period, effective 09/24/2024 to 11/27/2024. On 11/05/2024, the CTI was signed for the recertification benefit period of 11/28/2024 to 01/26/2025, 23 days before the start of the benefit period. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/03/2024. A clinical record review revealed evidence that the Medical Director signed the Recertification of Terminal Illness (CTI) on 09/30/2024, 30 days before the start of the benefit period, effective 10/30/2024 to 12/28/2024. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/13/2024. A clinical record review revealed evidence that the Medical Director signed the Recertification of Terminal Illness (CTI) on 10/22/2024, 17 days before the start of the benefit period, effective 11/08/2024 to 01/06/2025. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/26/2023. A clinical record review revealed evidence that the Medical Director signed the Recertification of Terminal Illness (CTI) on 11/09/2023, 16 days before the start of the benefit period, effective 11/25/2023 to 01/23/2024. On 03/04/2024, the CTI was signed for the benefit period effective 03/24/2024 to 05/22/2024, 20 days before the start of the benefit period. On 05/06/2024, the CTI was signed for the benefit period effective 05/23/2024 to 07/21/2024, 17 days before the start of the benefit period. On 09/03/2024, the CTI was signed for the benefit period starting on 09/20/2024 to 11/18/2024, 17 days before the start of the benefit period. On 10/25/2024, the CTI was signed for the benefit period effective 11/19/2024 to 01/17/2025, 25 days before the start of the benefit period. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/23/2024. A clinical record review revealed evidence that the Medical Director signed the Recertification of Terminal Illness (CTI) on 03/05/2024, 18 days before the start of the benefit period, effective 03/23/2024 to 05/21/2024. On 07/02/2024, the CTI was signed for the benefit period effective 07/21/2024 to 09/18/2024, 19 days before the start of the benefit period. On 09/03/2024, the CTI was signed for the benefit period from 09/19/2024 to 11/17/2024, 16 days before the start of the benefit period. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/09/2023. A clinical record review revealed evidence that the Medical Director signed the Recertification of Terminal Illness (CTI) on 10/08/2024, 24 days before the start of the benefit period, effective 11/01/2024 to 12/30/2024. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/27/2024. A clinical record review revealed evidence that the Medical Director signed the Recertification of Terminal Illness (CTI) on 08/07/2024, 18 days before the start of the benefit period, for the benefit period 08/25/2024 to 10/23/2025. On 09/30/2024, the CTI was signed for the benefit period effective 10/24/2024 to 12/22/2024, 24 days before the start of the benefit period. During an interview with the Medical Director on 01/16/2025, she stated that she was unaware that the recertification Certification of Terminal Illness could not be completed more than 15 days before the beginning of the next benefit period.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards a copy of the hospice discharge summary to the receiving facility. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed revealed the agency did not ensure that a copy of hospice discharge summary was sent to the facility receiving the patient. Document 1: The agency policy titled Discharge from Hospice stated in part “When the patient is discharged from hospice the hospice provides a copy of the clinical record and the hospice discharge summary to the patient’s attending physician and any new agency providing care”. CLINICAL RECORD 13: The patient elected hospice services on 05/24/2024 and was transferred to another hospice agency on 10/26/2024. The clinical record did not contain evidence that the discharge summary was sent to the receiving hospice agency. During an interview with the consultant on 01/16/2025, the consultant stated she did not know why the discharge summary was not sent to the receiving hospice.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed, in which the patient was discharged, revealed that the agency did not ensure a discharge summary was sent to the patient’s attending physician following a revocation or discharge from hospice. Agency policy, Discharge from Hospice, stated in part, “When the patient is discharged from hospice the hospice provides a copy of the clinical record and the hospice discharge summary to the patient’s attending physician.” CLINICAL RECORD 14: The patient elected hospice services on 03/06/2024 and chose to revoke hospice services on 06/14/2024. The clinical record did not contain evidence that the discharge summary was sent to the attending physician. During an interview with the consultant on 01/16/2025, the consultant stated that the attending physician was the Medical Director. When asked if the Medical Director would continue to follow the patient as the attending physician after discharge, the answer was no, the patient was choosing a different primary care physician.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by interview and personnel record review. In 2 of 6 (33%) personnel record review revealed the agency did not ensure a criminal background check was obtained within 3 months of the date of employment. Personnel Record 1: The Registered Nurse was hired on 10/12/2023. At that time, the agency obtained consent for a background check; however, a review of the personnel file lacked evidence of background check results. Documentation of another permission for a background check signed 03/28/2024 was present but lacked evidence of background check results. Personnel Record 2: The certified nurse aide was hired on 10/29/2023. At that time, the agency obtained consent for a background check; however, a review of the personnel file lacked evidence of background check results. During an interview with the Medical Director/Administrator, she stated that she knew they had been doing background checks on employees. She stated that she does not know where they have gone, but she is sure they have been completed.”