Aurora Hospice LLC

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient live discharge, the agency did not ensure the patient was involved in the development of his or her plan of care. Agency policy No. 1-025 Discharge from Hospice Program, revised November 2021, required in part: “Procedure: 1. The hospice interdisciplinary group will develop a discharge plan. 2. The case manager will ensure the necessary paperwork is completed at the time of discharge. This will include a signed revocation form, if necessary, and a written order to discharge if appropriate.” Clinical Record 11: The patient elected the hospice benefit on 06/13/2023 for the diagnosis of Alzheimer’s disease. The patient was discharged from hospice services for extended prognosis on 04/12/2024. Clinical record review revealed the Notification of Medicare Non-Coverage [NOMNC] form was signed by the patient/family on the day of discharge, instead of the required 48 hours before discharge. There was no documentation in the clinical record that the patient was involved in the development of the discharge plan. During an interview and record review on 01/23/2025, the Chief Compliance Officer agreed the NOMNC should have been given “earlier than the day of discharge.””

“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 clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed within five calendar days of the election of hospice care. Clinical Record 11: The patient elected the hospice benefit on 06/13/2023 for the diagnosis of Alzheimer’s disease. Clinical record review revealed no documented evidence that the Social Worker completed the psychosocial assessment as part of the initial comprehensive assessment. Clinical Record 13: The patient elected the hospice benefit on 07/08/2023 for the diagnosis of malignant neoplasm of skin. Clinical record review revealed no documented evidence that the Social Worker completed the psychosocial assessment as part of the initial comprehensive assessment. During an interview and joint review of records on 01/22/2025, the Chief Compliance Officer confirmed the Social Worker did not complete the initial social worker assessments and that there had “previously been an issue with documentation with the Social Worker.””

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure the drug profile contained the patient’s current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 11/19/2024 for a diagnosis of dementia with Lewy bodies. The patient resided in a group home. During the home visit observation with the Social Worker (SW) (Personnel Record 5) on 01/22/2025, the hospice medication profile (printed on 01/21/2025) was compared to the Group Home medication profile (printed on 01/22/2025). The hospice medication profile included the following medication that was not documented on the Group Home medication profile: An order dated 12/09/2024 for Calmoseptine 0.44 (1) ointment topical as needed after diaper change. There was also a discrepancy noted on an order dated 11/19/2024 for Acetaminophen. The hospice list had 325 mg 2 tablets every 6 hours as needed for pain or fever and the group home list had 325 mg 2 tablets every 6 hours scheduled. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 11/19/2024 for a diagnosis of Parkinsons disease. The patient resided in a skilled nursing facility. During the home visit observation with the Hospice Aide (HA) (Personnel Record 7) on 01/23/2025, the hospice medication profile (printed on 01/22/2025) was compared to the SNF medication profile (printed on 01/23/2025). The SNF list documented the following medications that were not documented on the hospice medication profile: 01/7/2025 Artificial tears instill 1 drop in both eyes twice daily as needed for dry eyes; 12/21/2024 Ativan 0.5 mg give 1 tablet by mouth every 8 hours as needed for restlessness or anxiety; 01/07/2025 Glucose gel 15gm/32 ml Give 15 grams by mouth as needed for hypoglycemia; 01/07/2025 Melatonin 5 mg by mouth at bedtime, 01/07/2025 Mylanta 400mg/5 ml take 20 ml three times a day as needed for heartburn, 01/07/2025 Vitamin B12 500 mcg give 2 tablets by mouth daily for supplement. The SNF record also included Carbidopa-Levodopa 25-100 mg Give 1 tablet by mouth four times daily and Milk of Magnesia 400mg/5ml Give 30 ml daily as needed for constipation. The hospice medication profile listed Carbidopa-Levodopa 25 mg Give 1 tablet every four hours and Milk of Magnesia 400mg/5ml Give 5 ml daily as needed for constipation. A joint clinical record review and interview was conducted on 01/23/2025 with the Chief Compliance Officer and Hospice Consultant in which the policy for medication reconciliation was discussed and it was determined the nurses “would need to be reminded to do weekly reviews.””

“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, observation, and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and updated the individualized care plans as frequently as the patient’s condition required. Clinical Record 1/Home Visit 1: During the home visit observation on 01/22/2025 with the Social Worker (SW) (Personnel Record 5), the plan of care was reviewed, and the SW was interviewed. The plan of care did not include problems, goals, and interventions related to the SW’s current goals and interventions discussed with the patient, caregivers, and family. The SW explained she was providing “socialization for the patient, assisting with resources regarding end-of-life planning for the family and support and updates as patient lived in the group home.” The SW agreed she needed to add these problems, goals, and interventions and update to the current plan of care. Clinical Record 2/Home Visit 2: During the home visit observation on 01/22/2025 with the Registered Nurse (RN) (Personnel Record 2), the plan of care was reviewed, and RN was interviewed. The RN described multiple medication changes regarding cardiac issues within the last two weeks, spoke about edema on the patient’s legs, and a recent episode of a cough that required medication changes. A joint clinical record review revealed the plan of care was not updated to reflect the changes in the patient’s condition described by the RN. Clinical Record 3: The patient elected the hospice benefit on 11/19/2024. The initial plan of care dated 11/19/2024 included a problem for “Potential for impaired mobility.” Clinical record review revealed the patient had 2 falls requiring on-call visits from the hospice during the week of 01/07/2025 through 01/11/2025 in which the patient was described as “being found on the floor, almost catatonic.” Mobile x-rays were ordered, and the patient had multiple medication changes on 01/07/2025. The goals and interventions in the plan of care were not updated related to the change in the patient’s condition. Clinical Record 5: The patient elected the hospice benefit on 07/11/2024 for the diagnosis of cerebrovascular disease. The Social Worker documented on the initial assessment that the patient and family “were recently homeless, needed help with financial assistance; needed help with transportation for grocery shopping, needs adult day care.” The assessment also included documentation that the patient needed help “coping with the diagnosis.” The plan of care was not updated to include problems, goals, and interventions related to the patient’s current status assessed by the Social Worker. Clinical Record 7: The patient elected the hospice benefit on 07/05/2024. The clinical record included a physician order dated 09/26/2024 for a Physical Therapy evaluation “to determine baseline mobility.” Clinical record review revealed no documented evidence that the plan of care was updated or revised related to the Physical Therapy evaluation. During an interview and joint review of records on 01/23/2025, the Director of Nursing, the Chief Compliance Officer, and the Hospice Consultant discussed plan of care updates and agreed that “they needed to update the plans of care more frequently.””

“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, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure the staff performed hand hygiene as required by agency policy. Agency policy No. 7-009-2003 Hand Hygiene, revised November 2021, required in part, “Personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC regulations and guidelines for hand hygiene in healthcare settings. Hand decontamination should be performed: A. Before having direct contact with patients. C. After contact with a patient’s intact skin (when taking a pulse, blood pressure, or lifting a patient). F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.” Home Visit 3: During the home visit observation on 01/23/2025 with Hospice Aide (HA) (Personnel Record 7), the HA was observed to push the patient in a wheelchair into the facility shower room. The HA then assisted the facility aide to move another patient from a wheelchair to a commode. After assisting the facility aide with the other patient, the HA returned to the original patient and began to shower the patient. The aide did not change gloves, nor wash her hands between patient contact. The HA was observed to have contact with two separate patients and three pieces of medical equipment and did not wash hands or change gloves during the entire process. An interview was conducted with the Chief Compliance Officer, the Director of Nursing, and the Hospice Consultant on 01/23/2025 in which the observation of the visit was described. Leadership agreed the aide did not comply with agency policy.”

“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. This standard was not met as evidenced by document review, personnel record review, and interview. In 4 of 8 (50%) personnel records reviewed, the agency did not ensure the skills and competencies of individuals providing care were assessed as required by agency policy. Agency policy No. 3-005 Annual Core Competence, revised November 2021, required in part, “Hospice personnel will demonstrate proficiency in the performance criteria/skills during the orientation period, at least annually thereafter as part of the annual performance evaluation process.” Personnel Record 2: Administrator/Director of Nursing date of hire 08/30/2021. Personnel record review for this staff member with direct patient contact revealed no documented evidence of competency assessment. Personnel Record 4: Nurse Practitioner date of hire 07/29/2023. Personnel record review for this staff member with direct patient contact revealed no documented evidence of competency assessment. The competencies documented in the record included blank pages and did not include signatures. Personnel Record 5: Social Worker/Bereavement Coordinator date of hire 10/14/2022. Personnel record review for this staff member with direct patient contact revealed no documented evidence of competency assessment. Personnel Record 7: Hospice Aide date of hire 08/22/2023. Personnel record review for this staff member with direct patient contact revealed no documented evidence of competency assessment. The competencies documented in the record included blank pages and did not include signatures. During an interview on 01/22/2025, the Chief Compliance Officer and the Hospice Consultant agreed the competencies had “missing portions and would need to be re-done.””

“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 14 (14%) clinical records reviewed, the agency did not ensure the clinical record included complete physician orders. Clinical Record 7: The patient elected the hospice benefit on 07/05/2024 with a diagnosis of hypertensive heart disease. Clinical record review revealed a physician order dated 07/05/2024 for “Wound care Stage I on l (left) and r (right) buttock, Cleanse with N/S (normal saline) pat dry with gauze, Apply with Calmoseptine, reposition every 1-2 hours.” The order did not include the frequency the wound care should be provided. Clinical Record 8: The patient elected the hospice benefit on 01/07/2025 with a diagnosis of congestive heart failure. Clinical record review revealed a physician order dated 01/14/2025 for “Transfer patient to GIP (general inpatient) for 7-10 days for symptom management.” The order did not specify that GIP is a change in the level of care and not an actual patient transfer and did not include that GIP level of care should be reevaluated daily related to the patient’s symptoms. During an interview on 01/22/2025, the Director of Nursing and the Hospice Consultant explained the Consultant’s education “might have been mistaken when they called her about the GIP. She said they could have GIP for up to 7-10 days if the patient remained appropriate and somehow that the order got written that way.””

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident. The most recent hospice plan of care. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) clinical record reviewed in which the patient resided at an SNF/NF [skilled nursing facility], the agency did not ensure the designated IDG member provided the SNF/NF with the patient’s most recent hospice plan of care. Home Visit 3: The patient elected the hospice benefit on 11/19/2024 with a diagnosis of Parkinson’s disease. The patient resided in a SNF. During the home visit observation on 01/23/2025 with the Hospice Aide (HA) (Personnel Record 7), review of the facility binder provided to the SNF by the hospice revealed no documented evidence that the facility was provided with the patient’s most recent hospice plan of care. A joint interview was conducted with the Director of Nursing, the Chief Compliance Officer, and the Hospice Consultant on 01/23/2025. The facility binder was discussed, and the Chief Compliance Officer advised the “Case Manager was responsible for ensuring items were present at the facility.””

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness for each patient/resident. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) clinical record reviewed in which the patient resided at an SNF/NF [skilled nursing facility], the agency did not ensure the designated IDG member provided the SNF/NF with the physician certification and recertification of the terminal illness. Home Visit 3: The patient elected the hospice benefit on 11/19/2024 with a diagnosis of Parkinson’s disease. The patient resided in a SNF. During the home visit observation on 01/23/2025 with the Hospice Aide (HA) (Personnel Record 7), review of the facility binder provided to the SNF by the hospice revealed no documented evidence that the facility was provided with the physician certification and recertification of the terminal illness. A joint interview was conducted with the Director of Nursing, the Chief Compliance Officer, and the Hospice Consultant on 01/23/2025. The facility binder was discussed, and the Chief Compliance Officer advised the “Case Manager was responsible for ensuring items were present at the facility.””

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the names and contact information for hospice staff involved in the patient’s care. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) clinical record reviewed in which the patient resided at an SNF/NF [skilled nursing facility], the agency did not ensure the designated IDG member provided the SNF/NF with the names and contact information for hospice staff involved in the patient’s care. Home Visit 3: The patient elected the hospice benefit on 11/19/2024 with a diagnosis of Parkinson’s disease. The patient resided in a SNF. During the home visit observation on 01/23/2025 with the Hospice Aide (HA) (Personnel Record 7), review of the facility binder provided to the SNF by the hospice revealed no documented evidence that the facility was provided with the names and contact information for hospice staff involved in the patient’s care. A joint interview was conducted with the Director of Nursing, the Chief Compliance Officer, and the Hospice Consultant on 01/23/2025. The facility binder was discussed, and the Chief Compliance Officer advised the “Case Manager was responsible for ensuring items were present at the facility.””