H & A Hospice Inc.

“Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient’s Rights and Responsibilities in a language and manner that the patient understands. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.”

“Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patients 4, 5, 6, 7, 11, 12, 13, 14:Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.”

“Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the hospice obtained the patient’s or representative’s signature confirming that they received a copy of the Patient’s Rights and Responsibilities. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.”

“Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 8, 11, 12, 13, 14) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.”

“Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the patient received information about the services covered under the hospice benefit. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.”

“Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.”

“Upon patient record review, 10 of 16 (Patient #1,2,3,4,5,6,7,8,10,15) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients 1, 2, 3 , 4, 5, 6, 7, 8, 10, 15: Initial bereavement assessment has no name, relationship or contact information for person assessed.”

“Upon patient record review, 1 of 16 (Patient #3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 3: SN frequency 1x/week and 2 prn. There are no documented RN visits 11/05/25 -12/3/25.”

“Upon patient record review, 1 of 16 (Patient #11) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 11: Patient was hospitalized on 12/10/24 with no explanation of circumstance and no documented follow-up until MD ordered discharge on 12/26/24. The IDG note from 12/16/24 states patient was hospitalized and will continue to monitor. There was no documented evidence by the nurse of follow up and continuous assessment of the patient and family’s needs.”

“Upon patient record review, 5 of 16 (Patient #3, 4, 5, 6, 8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patients 3, 8: Spiritual counselor visits were phone calls without problems, goals and interventions in the plan of care. Patients 4: Patient admitted with cardiac pacemaker according to CTI and diagnoses. There is no reference to pacemaker in problems, goals and interventions. Patients 5, 6: Diagnosis of seizure disorder listed with no related problems, goals and interventions.”

“Upon patient record review, 16 of 16 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patients 1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16: Patient admitted with orders for MSW and SC 1x/month. Patients declined services on initial assessment visits by each discipline, with no updated frequency orders to the plan of care. Patients 7, 8: Patient admitted with orders for MSW 1x/month. Patient declined additional visits during initial MSW assessment visit. Frequency orders were not updated to reflect patient choice.”

“Upon client record review, 3 of 16 (Patient #3, 8, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: 10/10/25 assessment visits describe home visit, but that patient declined. 10/20/25 IDG SC noted Chaplain made contact with patient by phone to offer and explain SC services and schedule an initial visit.....not interested in the SC services at this time... Chaplain will not schedule. However 11/11/25 note states spiritual phone call provided and plan to continue monthly calls. In addition, SN frequency 1x/week and 2 prn. There are no documented visits 11/05/25 -12/3/25. Patient 8: Spiritual counselor visits were phone calls and no order documented in the record. Patient 14: Patient documented as passed away 8/16/25 related to lethal food allergy, but there is documentation of 8/21/25 SN visit 100-300 pm, describing the patient as alert, oriented, restless, including vital signs.”

“Upon patient record review, 1 of 16 (Patient #10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 10: Hospice aide frequency 1x/week. Tasks assigned have no specified frequency. Oxygen flow rate included, but not safety precautions. (applicable to both care plans both benefit periods.)”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. This lack of oversight is demonstrated by the hospice’s inability to provide complete and readily accessible medical records at the start of survey. During the survey process the hospice failed to provide requested documentation in a timely manner, reflecting a lack of administrative organization, lack of record management, and effective oversight. Hospice agencies are expected to maintain organized, complete, accurate, and readily accessible clinical records to demonstrate compliance with regulations.”

“Upon patient record review, 3 of 16 (Patient #7, 11, 14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 7: 7/5/24 SC initial assessment notes that patient was finding it difficult to receive news that she has cancer. There was no other reference to cancer for this patient in the record. Patient 11: End of Care summary notes that patient was hospitalized 12/10/25. The 12/16/25 IDG notes that patient was hospitalized 12/8/25. Patient 14: 2/16/26 Bereavement support call scheduled for 2/16/26 was inadvertently marked done. (but was not actually completed when opened).”

“Upon client record review, 2 of 16 (Patient #11, 12) did not have evidence that the discharge summary includes all required information. Patient 11: Discharge summary does not address any change in patients condition and/or signs/symptoms resulting in hospitalization. There is no evidence of hospice notification/coordination of care with hospital where patient had been hospitalized (12/10-12/26/25 date of hospice discharge). There is also no documented evidence of communication/coordination with hospital related to discharge date. Patient 12 Upon discharge record review, there is no evidence of any information provided to receiving organizations. The patient chose to “search for another hospice, with no additional info provided.””