Bristol Hospice- Greater Los Angeles

“It is required that the written Patient Bill of Rights includes the right to: receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-018 “Pain Assessment” (dated 05/2020) read in part, “When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: Pain intensity using a rating scale ... Pain location and frequency; Pain quality, patterns of radiation, and character ... Pain onset, duration, variations, and patterns; Alleviating and aggravating factors; Present pain management regimen and effectiveness ...Effects of pain... The patient’s pain goal, including pain intensity and goals related to function, activities, and quality of life ... If a patient is unable to communicate pain using the rating scale and is cognitively impaired ... the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment ...” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient received effective pain management and symptom control for symptoms. Clinical Record 1: The patient elected the hospice benefit on 01/31/2023 with a diagnosis of Alzheimer’s Disease. The patient resided in an assisted living facility (ALF). The Skilled Nurse (SN) visit note dated 10/08/2024 documented an “Edmonton pain score of five (5)...the patient/caretaker denied pain...Patient has also developed poor trunk support that has resulted in the inability to sit long in her reclining W/C, so she is staying in bed most of the time ... Patient continues to scream. No pain or discomfort noted this visit.” On 10/15/2024, the SN visit note documented an Edmonton pain score (The Edmonton Classification System for Cancer Pain is a validated assessment instrument for pain classification in cancer patients) of six (6) and, in the section for pain, documented that the and “noted with superficial skin breakdown on sacrococcyx ... Due to long stay in bed, patient is constantly getting ... excoriation ... denies any pain or discomfort.” The physician’s Certification of Terminal Illness dated 09/22/2024 to 11/20/2024 documented, “The pt has lost truncal support during this benefit period. She is only placed in a chair at her daughter’s insistence. She has pain and requires support in the chair...” The patient’s plan of care included an order dated 01/31/2023 for Acetaminophen 325mg - two tablets by mouth every six hours as needed for pain. No comprehensive pain assessment was performed on 10/08/2024 and 10/15/2024 when the SN documented the patient’s pain score as five (5) and six (6), respectively. Clinical Record 3: The patient elected the hospice benefit on 08/06/2024 with a diagnosis of malignant neoplasm of the colon. The patient resided at home. On 08/06/2024, the physician ordered “Acetaminophen/Codeine 325mg/10mg every six hours by mouth for pain” and “MS Contin 30mg extended release every twelve hours by mouth for pain.” On 08/30/2024, the physician ordered Roxanol 20mg/5ml: 0.5 ml by mouth every four hours as needed for pain. The SN routine visit note completed by the Licensed Vocational Nurse (LVN) dated 09/17/2024 documented a pain score of seven (7) on the Edmonton scale for pain. On 09/23/2024, the SN visit note documented the patient’s pain score of four (4) on the Edmonton scale for pain. On 09/30/2024, the Registered Nurse (RN) routine visit note documented, “Patient was noted with grimacing this visit even though she takes Roxanol as needed as directed. Caregiver administered a dose of Roxanol during this visit ... Upon further review of patient’s medication, patient has order of MS Contin 30mg. Refill request sent to the pharmacy...” On 10/07/2024, the nurse documented a pain score of three (3). During the SN visits dated 10/14/2024 and 10/28/2024, the patient’s pain score was four (4). There was no comprehensive pain assessment completed during the nursing visits during September or October 2024. During a joint clinical record review and interview on 11/06/2024, the Regional Director of Clinical Services confirmed that a comprehensive pain assessment was not performed in the two patients to further elaborate on what the nurses assessed during the documented visits.”

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes the characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); [and] the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-018 “Pain Assessment” (dated 05/2020) read in part, “When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: Pain intensity using a rating scale ... Pain location and frequency; Pain quality, patterns of radiation, and character ... Pain onset, duration, variations, and patterns; Alleviating and aggravating factors; Present pain management regimen and effectiveness ...Effects of pain... The patient’s pain goal, including pain intensity and goals related to function, activities, and quality of life ... If a patient is unable to communicate pain using the rating scale and is cognitively impaired ... the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment ...” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that a full pain assessment was completed when the nurse identified and documented that the patient had pain. Clinical Record 1: The patient elected the hospice benefit on 01/31/2023 with a diagnosis of Alzheimer’s Disease. The patient resided in an assisted living facility (ALF). The Skilled Nurse (SN) visit note dated 10/08/2024 documented an “Edmonton pain score of five (5)...the patient/caretaker denied pain...Patient has also developed poor trunk support that has resulted in the inability to sit long in her reclining W/C, so she is staying in bed most of the time ... Patient continues to scream. No pain or discomfort noted this visit.” On 10/15/2024, the SN visit note documented an Edmonton pain score (The Edmonton Classification System for Cancer Pain is a validated assessment instrument for pain classification in cancer patients) of six (6) and, in the section for pain, documented that the and “noted with superficial skin breakdown on sacrococcyx ... Due to long stay in bed, patient is constantly getting ... excoriation ... denies any pain or discomfort.” The physician’s Certification of Terminal Illness dated 09/22/2024 to 11/20/2024 documented, “The pt has lost truncal support during this benefit period. She is only placed in a chair at her daughter’s insistence. She has pain and requires support in the chair...” The patient’s plan of care included an order dated 01/31/2023 for Acetaminophen 325mg - two tablets by mouth every six hours as needed for pain. No comprehensive pain assessment was performed on 10/08/2024 and 10/15/2024 when the SN documented the patient’s pain score as five (5) and six (6), respectively. Clinical Record 3: The patient elected the hospice benefit on 08/06/2024 with a diagnosis of malignant neoplasm of the colon. The patient resided at home. On 08/06/2024, the physician ordered “Acetaminophen/Codeine 325mg/10mg every six hours by mouth for pain” and “MS Contin 30mg extended release every twelve hours by mouth for pain.” On 08/30/2024, the physician ordered Roxanol 20mg/5ml: 0.5 ml by mouth every four hours as needed for pain. The SN routine visit note completed by the Licensed Vocational Nurse (LVN) dated 09/17/2024 documented a pain score of seven (7) on the Edmonton scale for pain. On 09/23/2024, the SN visit note documented the patient’s pain score of four (4) on the Edmonton scale for pain. On 09/30/2024, the Registered Nurse (RN) routine visit note documented, “Patient was noted with grimacing this visit even though she takes Roxanol as needed as directed. Caregiver administered a dose of Roxanol during this visit ... Upon further review of patient’s medication, patient has order of MS Contin 30mg. Refill request sent to the pharmacy...” On 10/07/2024, the nurse documented a pain score of three (3). During the SN visits dated 10/14/2024 and 10/28/2024, the patient’s pain score was four (4). There was no comprehensive pain assessment completed during the nursing visits during September or October 2024. During a joint clinical record review and interview on 11/06/2024, the Regional Director of Clinical Services confirmed that a comprehensive pain assessment was not performed in the two patients to further elaborate on what the nurses assessed during the documented visits.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-027 “Missed Visits” (dated 05/2020) stated in part, “If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician-ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled, the clinician will: Notify the IDG .... of the missed visit and the reason for the missed visit. Document in the patient’s clinical record the following information: Patient name; Date and type of visit that was missed; Reason for the missed visit; Description of any unmet needs and how the patient’s needs were met... Other person(s) that were notified of the missed visit ...” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that care and services followed the individualized plan of care (POC). Clinical Record 2: The patient elected the hospice benefit on 04/29/2024 with a diagnosis of Alzheimer’s Disease. The patient resided at home. The plan of care dated 07/28/2024 to 10/25/2024 ordered the Social Worker (SW) once (1) a month. The SW documented phone visits on 07/26/2024 and 10/31/2024. A clinical record review revealed no Social Worker visits for August or September 2024. The SW note dated 09/20/2024 documented, “Appointment for Aug 30, 2024, canceled on Sep 20, 2024 ... because other.” No note was documented for the missed visit in September, and no reason was provided for the missed visit in August, as per the policy. Clinical Record 3: The patient elected the hospice benefit on 08/06/2024 with the diagnosis of malignant neoplasm of the colon. The plan of care for 08/06/2024 to 11/03/2024 ordered Skilled Nursing (SN) services once a week. The week of 09/02/2024 there was no evidence that a SN visit was completed. The SN completed a note on 09/03/2024 that documented, “Appointment for Sep 2, 2024, canceled on Sep 3, 2024 ... because other (Registered Nurse) RN has car problem.” During an interview on 11/07/2024, the Regional Director of Clinical Operations confirmed that if the clinician is unable to visit for some reason, the clinician should attempt to move the visit to another day, notify the office to find out if there is another clinician available that same day, but missed visits should occur because of the patient/family choice.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] and 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, document review, and interview. Agency policy #9-017, “The Plan of Care” (dated 09/2024), stated in part, “The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments ... This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development and continued updating of the plan of care... Each patient will be monitored for his/her response to care or services provided against established patient goals and identified outcomes to evaluate progress toward goals... Any change in the patient’s condition must result in a change in the plan of care prior to implementation of the new service ... The written plan of care can contain but will not be limited to ... individualized interventions to assist with end-of-life care .... Statement of treatment goals ... pain and symptom management interventions...” In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected the goals of the patient/family and identified interventions based on problems identified in the comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 01/31/2023 with the diagnosis of Alzheimer’s Disease. The patient resided in an assisted living facility (ALF). The nurse practitioner (NP) visit note dated 08/26/2024 documented, “Her restlessness and agitation required repeated assessment and readjustment of her antipsychotic and antidepressant medication ...” The physician’s Certification of Terminal Illness for the benefit period 09/22/2024 to 11/20/2024 documented “has declined manifested by an exacerbation of behavioral disturbances requiring the adjustment and addition multiple pharmacologic interventions .... She has pain and requires support in the chair... “ There was a physician order documented on 12/05/2023 for Lexapro five milligrams (mg) by mouth daily. On 02/01/2024, an order was documented for Quetiapine fifty mg by mouth at bedtime for agitation. On 02/02/2024, another order was documented for Quetiapine 25mg by mouth at 8 AM each morning for agitation. On 04/03/2024, the physician ordered 150mg of Trazodone by mouth every night at bedtime, and on 04/18/2024, the physician ordered Lorazepam one (1) mg by mouth nightly at bedtime. On 05/29/2024, a third order was documented for Quetiapine 75mg by mouth daily at 2 PM for agitation. The plans of care dated 03/26/2024 to 05/24/2024, 05/25/2024 to 07/23/2024, 07/24/2024 to 09/21/2024, and 09/22/2024 to 11/20/2024 did not include documentation of identified patient or family goals for agitation or insomnia. Clinical Record 2: The patient elected the hospice benefit on 04/29/2024 with the diagnosis of Alzheimer’s Disease. The patient resided at home. The Registered Nurse (RN) visit note dated 09/04/2024 documented, “Patient has a left thumb infection. New order ... to start Keflex 250mg 1 capsule po qid x 7 days...” On 10/08/2024, the RN documented that the patient’s left thumb was red and swollen. The physician was contacted and ordered Keflex again for seven days. Physician’s orders were documented on 09/04/2024 and 10/08/2024 for Cephalexin (Keflex) 250mg by mouth four times a day for seven days for a left thumb infection. The plan of care dated 07/28/2024 to 10/25/2024 ordered the antibiotic with the indication of a thumb infection. The plan of care did not include documentation of the identified patient or family goals for the patient’s thumb infection. The RN visit note dated 10/01/2024 documented, “New order received ... to start MOM 15ml by mouth daily, as Senna 8.6mg one (1) tab po daily seems inadequate ...” On 10/29/2024, the SN visit note documented, “patient has a daily bowel movement, formed and hard, patient is constipated. New order to start Senna S two (2) tabs po at bedtime... Refilled MOM ...” On 10/01/2024, the physician ordered Milk of Magnesia 8% Suspension 15ml by mouth daily for constipation. On 10/15/2024, the physician ordered Senna-S 50mg/8.6mg - two tablets by mouth every day for constipation. The plan of care dated 07/28/2024 to 10/25/2024 included the order for the laxatives for constipation. The plan of care did not include documentation of the identified patient or family goals for the patient’s constipation. Clinical Record 3: The patient elected the hospice benefit on 08/06/2024 with a diagnosis of malignant neoplasm of the colon. The physician’s Certification of Terminal Illness for 08/06/2024 to 11/03/2024 documented “58 y/o female w/dx of Colon CA comorbid Schizophrenia ... The pt is agitated, aggressive, and resistant to care... The pt wielded scissors and a toy gun when nursing visited her...” For the benefit period 11/04/2024 to 02/01/2025, the physician noted on the Certification of Terminal Illness documented “ comorbid Bipolar dis ... ... decline manifested by worsening behavioral disorder w/ sociopathic behaviors. The pt is irritable and intolerant. The pt refuses Assisted Living and long-term care. ... The pt is delusional and paranoid. She may be a Paranoid Schizophrenic...” The Registered Nurse’s visit note dated 10/28/2024 documented a “diagnosis of colon cancer. Co-morbidities are ... bipolar and have very erratic behavior... She is noncompliant with medication ...” There was an order for Lorazepam one (1) mg by mouth every six hours dated 08/12/2024 with no indication for use documented. No other psychiatric or behavioral medications were included in the patient’s plan of care dated 08/06/2024 to 11/03/2024 and 11/04/2024 to 02/01/2024. The plans of care did not include the identification of a problem with patient-specific interventions or defined goals related to the patient’s erratic, aggressive, non-compliant behavior. The Social Worker added new goals on 10/30/2024 that the patient’s social/emotional problems would be resolved. During a joint record review and interview on 11/06/2024, the Regional Director of Clinical Operations confirmed that the patient’s clinical record did not include interventions to address the management of the patient’s identified behavioral issues. On 08/06/2024, the physician ordered Zofran 4mg orally disintegrating tablet by mouth every six hours as needed for nausea and vomiting. The patient’s plan of care dated 08/06/2024 to 11/03/2024 and 11/04/2024 to 02/01/2024 included the order for Zofran with the indications for use. The plans of care were not updated to include identified patient goals for the nausea. On 09/17/2024, the SN visit note documented, “Existing wound noted to rectal/vaginal area with breakdown, scan blood and malodorous. Patient complained she could smell a bad odor coming from her private area... new orders ... Keflex oral 500 mg one (1) tablet by mouth QID x 10 days and Keflex oral 500mg one (1) tablet by mouth daily to follow ..” On 09/17/2024, the RN visit note documented, “Upon assessment of prolapse rectal wound looks macerated and have some odor ... MD made aware and ordered flagyl powder to sprinkle on site...” A physician’s order was documented on 09/17/2024 for Cephalexin (Keflex) 500mg by mouth four times a day for ten days for wound infection. On 09/23/2024, the physician ordered Flagyl 500mg: two tablets applied topically twice a day as needed to decrease wound odor. Another order was documented on 09/28/2924 to continue Cephalexin 500mg by mouth once a day after the completion of the ten-day therapeutic dose. The plan of care for 08/06/2024 to 11/03/2024 included the medication orders, which indicated that they were prescribed for the patient’s wound infection. The plan of care did not include documentation of the identified patient or family goals for treating the wound with these medications. The Interdisciplinary Group Meeting dated 10/30/2024 documented the nursing goals: the patient will be compliant with pain medications, maximum comfort will be reached, and the prevention of any complications or injury. The Social Worker added new goals on 10/30/2024 that the patient’s social/emotional problems would be resolved. On 11/04/2024, the physician ordered Lasix 20mg by mouth daily for pedal edema and Potassium Bicarbonate 10 mEq by mouth daily. The patient’s plan of care, dated 11/04/2024 to 02/01/2024, included the orders for Lasix with their indications for use, but the plan of care was not updated to include identified patient goals. Clinical Record 4: The patient elected the hospice benefit on 08/21/2024 with a diagnosis of Alzheimer’s Disease. The patient resided at home. The physician’s Certification of Terminal Illness for 08/21/2024 to 11/18/2024 documented, “The pt has developed worsening confusion and agitation recently ... “ A physician’s order for Quetiapine 24mg by mouth daily for “other” was documented on 08/21/2024. The order did not include the indication for use. The RN visit note dated 09/24/2024 documented, “per pt daughter ... pt is more confused, agitated and seeing dead people and hallucination, taking lorazepam one (1) tab po at night and effective per daughter ...” The order was discontinued on 10/01/2024, and a new order was documented for Quetiapine 25mg twice daily by mouth for mood. The plan of care dated 08/21/2024 to 11/18/2024 did not include documentation of an identified problem related to the patient’s agitation until the order identified the reason for the use of Quetiapine on 10/01/2024. There was no documentation of the patient’s/family’s goals of care for the treatment with Quetiapine. Clinical Record 6: The patient elected the hospice benefit on 11/12/2022 with the diagnosis of Alzheimer’s Disease. On 11/15/2022, the physician ordered Seroquel 50mg by mouth daily for behavior management and Seroquel 100mg by mouth nightly for behavior management. On 06/12/2024, the physician ordered Xanax 0.25mg by mouth every eight hours as needed for anxiety. The Licensed Vocational Nurse (LVN) visit note dated 06/13/2024 documented, “Per cg prior visit she provided pt with lorazepam 1mg sl q6 hours due to pt was restless. Lorazepam is effective at this time.” The RN visit note dated 09/24/2024 documented, “Patient has episodes of anxiety and agitation... New orders ... Lexapro 5mg 1 tab po daily for agitation...” On 09/24/2024, the physician ordered Lexapro 5mg by mouth daily for behavior management. During the IDG Meeting on 10/16/2024, the RN documented, “Patient has episodes of anxiety and given Alprazolam and Lexapro ...” The physician’s Certification of Terminal Illness for 11/01/2024 to 12/30/2024 documented, “96 y/o female with Alzheimer’s Dementia w/schizoaffective disorder ... The pt has episodes of anxiety and restlessness that have been addressed w/SSRI (selective serotonin reuptake inhibitors are a class of medications most commonly prescribed to treat depression) w/some improvement...” The patient’s plans of care dated 05/05/2024 to 07/03/2024, 07/04/2024 to 09/01/2024, 09/02/2024 to 10/31/2024 and 11/01/2024 to 12/30/2024 did not include documentation of identified patient or family goals for the treatment of behavior problems with the Seroquel, Lexapro, or Xanax. Clinical Record 9: The patient elected the hospice benefit on 03/23/2021 with a diagnosis of Parkinson’s disease. The patient resided in an assisted living facility (ALF). The RN visit note dated 10/17/2024 documented the patient’s blood pressure reading of 123/68. On 10/20/2024, the physician ordered Midodrine 2.5mg by mouth every eight hours as needed for dizziness. The SN visit note dated 10/22/2024 documented that the patient’s blood pressure was 104/65, the patient complained of increased fatigue and weakness, and the ALF had fall precautions in place. The blood pressure reading noted during the SN visit dated 10/25/2024 was 99/64. The Interdisciplinary Group Meeting on 10/22/2024 included the order for Midodrine for dizziness. There were no parameters included in the order for when the medication should be given. The plan of care dated 10/15/2024 to 12/13/2024 did not include documentation of identified patient or family goals for the use of the medication. During a joint record review and interview on 11/07/2024, the Regional Director of Clinical Operations confirmed that patient-specific and patient/family-directed goals were not identified in the patient’s plans of care.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 3: The patient elected the hospice benefit on 08/06/2024 with a diagnosis of malignant neoplasm of the colon. The patient resided at home. The LVN visit note dated 09/17/2024 documented that the patient was alert and oriented and had a pain score of seven. On 09/23/2024, the Registered Nurse (RN) documented that the patient complained of pain and rated the pain at a four. On 10/07/2024 and 10/14/2024, the nurse documented pain scores of three and four, respectively. Physician’s orders were documented on 08/06/2024 for Acetaminophen - Codeine 325mg/10mg by mouth every six hours for pain and MS Contin Extended-Release 30 mg by mouth every twelve hours for pain. On 08/30/2024, the physician ordered Roxanol 20mg/ml - 0.5ml by mouth every four hours as needed for pain. The plan of care dated 08/06/2024 to 11/03/2024 included documentation of the medication orders with the indication that they were prescribed for pain. The goals related to comfort in the plan of care included “Skilled observation and assessment of comfort” and “Assess pain.” There was no identified goal with a measurable outcome for the patient’s acceptable pain score.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 1 of 19 (5%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that HA received written patient care instructions to meet the patient’s needs. Clinical Record 4: The patient elected the hospice benefit on 08/21/2024 with a diagnosis of Alzheimer’s Disease. The patient resided at home. The plan of care dated 08/21/2024 to 11/18/2024 ordered Hospice Aide services twice (2) a week. The HA care plan for the benefit period assigned the HA the task of brushing the patient’s teeth. The physician’s certification for the benefit period documented, “The pt’s O2 (oxygen) sat is in the 70’s on RA (room air). She requires 5 l/m of O2 via mask or nasal ... to achieve an O2 sat of 90% or greater..” The Registered Nurse (RN) visit notes dated 08/27/2024, 09/03/2024, 09/24/2024, and 10/15/2024 documented that the patient was on oxygen continuously at five (5) liters per minute via face mask. The HA care plan did not provide the HA with instructions regarding the patient’s use of oxygen during personal care. During an interview on 11/06/2024, the Regional Director of Clinical Operations confirmed the nurse should have instructed the aides regarding whether the oxygen can be removed during the patient’s care.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-027 “Missed Visits” (dated 05/2020) stated in part, “If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician-ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled, the clinician will: Notify the IDG .... of the missed visit and the reason for the missed visit. Document in the patient’s clinical record the following information: Patient name; Date and type of visit that was missed; Reason for the missed visit; Description of any unmet needs and how the patient’s needs were met... Other person(s) that were notified of the missed visit ... If an aide visit is missed, the aide will contact the Hospice Case Manager or clinical management. The Director of Patient Care Services/Clinical Supervisor will take the appropriate measures stated above... “ In 1 of 19 (5%) clinical records reviewed of patients that received Hospice Aide (HA) services, the HA did not provide services ordered by the Interdisciplinary Group. Clinical Record 1: The patient elected the hospice benefit on 01/31/2023 with the diagnosis of Alzheimer’s. The patient resided in an assisted living facility (ALF). The plan of care dated 07/24/2024 to 09/21/2024 ordered HA services three (3) times a week. A clinical record revealed two (2) HA documented visits for the week of 09/02/2024, 09/09/2024, and 09/16/2024. The HA visit note dated 09/03/2024 documented, “Appointment for Sep 2, 2024, canceled on Sep 3, 2024 ... because ... HCA was off.” On 09/16/2024, the HA documented, “Appointment for Sep 13, 2024, canceled on Sep 16, 2024 ... because ... HCA was off ... ALF will wait for next scheduled visit.” No missed visit note or communication was documented for the week of 09/09/2024. The two notes dated 09/03/2024 and 09/16/2024 documented that the visits were missed because the HA was not working. There was no evidence of efforts to find a substitute HA to visit the patient. During an interview on 11/07/2024, the Regional Director of Clinical Operations confirmed the finding, stating that if the clinician is unable to visit for some reason, the clinician should attempt to move the visit to another day and notify the office to find out if there is another clinician available that same day.”

“It is required that a hospice aide provides services: that are included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #9-020 “Hospice Aide Services” (dated 09/2024) read in part, “Hospice aides will document care provided in accordance with the hospice aide assignment...” In 2 of 19 (11%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that HA provided services included in the care plan. Clinical Record 2: The patient elected the hospice benefit on 04/29/2024 with a diagnosis of Alzheimer’s Disease. The patient resided at home. The plan of care dated 07/28/2024 to 10/25/2024 ordered Hospice Aide services twice (2) a week. The HA care plan for the benefit period assigned the HA the relevant task of documenting the patient’s last bowel movement every visit. The HA visits for September and October 2024 did not include documentation of the patient’s last bowel movement. Clinical Record 11: The patient elected the hospice benefit on 02/23/2022 with a diagnosis of other signs and symptoms involving cognitive function following a cerebral infarction. The plans of care dated 08/11/2024 to 10/09/2024 and 10/10/2024 to 12/08/2024 ordered Hospice Aide services three (3) times a week. The HA care plan for the benefit period assigned the HA the relevant task of documenting the patient’s last bowel movement every visit. The HA visits for September and October 2024 did not include documentation of the patient’s last bowel movement. During an interview on 11/06/2024, the Regional Director of Clinical Operations confirmed the aides did not document the date of the last bowel movement during their visits, and the nurse should instruct the aides regarding whether the oxygen can be removed during the patient’s care.”