Sacred Heart Hospice

“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 revealed the agency did not ensure the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completed 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. CLINICAL RECORD 13: The patient elected the hospice benefit on 01/09/2025. The initial nursing assessment dated 01/09/2025 noted the social worker and spiritual counselor were “declined.” The initial social and spiritual assessment was not completed by the registered nurse. No other disciplines visited the patient. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/30/2025. The initial nursing assessment dated 01/30/2025 noted the spiritual counselor was “declined.” The initial spiritual assessment was not completed by the registered nurse. An interview and joint clinical record review was conducted with the Administrator/DPCS on 04/09/2025, and she agreed there was not documentation of the initial psychosocial or spiritual comprehensive assessments on these clinical records.”

“It is required that 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 2 of 14 (14%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 3: The patient’s election of benefits was 01/29/2025 with diagnosis of Alzheimer’s disease. The plan of care beginning 01/29/2025 included an order for hospice aide frequency of twice a week. The hospice aide care plan dated 01/29/2025 included the following relevant tasks: “vital signs (temperature, blood pressure, pulse, respirations), bed bath, shampoo, comb hair, mouth care, shave, assist with dressing, clean nails, file nails, peri care, soak feet, skin care, passive ROM, prepare/feed meals, and change bed linens every visit.” The initial nursing assessment dated 01/29/2025 noted “Stage IV pressure ulcer to sacrum covered with foam dressing and a right heel pressure ulcer covered with dressing.” The aide plan of care did not include specific instructions to the aide for the wounds. CLINICAL RECORD 8: The patient’s election of benefits was 10/17/2024 with diagnosis of COPD. The hospice aide care plan dated 10/17/2024 included the following relevant tasks: shower, shampoo, comb hair, mouth care, shave, assist with dressing, clean nails, file nails, peri care, change bed linens every visit. The plan of care beginning 10/17/2024 included the aide frequency of twice weekly. The initial nursing assessment dated 10/17/2024 noted a “the patient was on 2-5 liters per minute of continuous oxygen.” The aide plan of care did not provide the aide with specific instructions for the oxygen during tasks. An interview and joint clinical record review was conducted with the Administrator/DPCS on 04/09/2025 in which it was agreed the aide care plans did not acknowledge the wounds in Clinical Record 3 or provide specific instructions for “what happened if the dressings came off.” The Administrator/DPCS also stated that the “aide would have to have instructions if they could briefly remove the oxygen” in regard to Clinical Record 8.”

“It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by interview and observation. In 1 of 14 (7%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide provided services included in the plan of care as ordered by the Interdisciplinary Group. Home Visit 3: The hospice aide care plan dated 01/29/2025 included the following relevant tasks: “vital signs (temperature, blood pressure, pulse, respirations), bed bath, shampoo, comb hair, mouth care, shave, assist with dressing, clean nails, file nails, peri care, soak feet, skin care, passive ROM, prepare/feed meals, and change bed linens every visit.” Aide visit frequency of twice weekly. During the home visit (Clinical Record 3) with the hospice aide (Personnel Record 6 ) on 04/09/2025, the Aide did not complete the following tasks listed on the aide plan of care: vital signs (temperature, blood pressure, pulse, respirations), shampoo, comb hair, mouth care, shave, file nails, soak feet, prepare/feed meals, and change bed linens every visit. An interview and joint clinical record review was conducted with the Administrator/DPCS on 04/09/2025. The tasks completed on the home visit were reviewed and the Administrator/DPCS agreed that several had not been completed that were listed on the aide care plan.”

“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 and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed in which aides services were accepted revealed the agency did not ensure a registered nurse 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 and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. CLINICAL RECORD 1: Hospice aide services were ordered for a frequency of three times weekly on 03/20/2025. The first aide visit occurred on 03/21/2025. There was a documented registered nurse visit on 03/23/2025, but the nurse checked N/A (not applicable) to aide supervision. There has not been a documented registered nurse supervisory visit since the aide started providing services as of the review date of 04/09/2025, 19 days. CLINICAL RECORD 2: Hospice aide services were ordered for a frequency of three times weekly on 09/05/2024. There was a documented registered nurse supervisory visit on 01/16/2025, and the next one was 02/13/2025, 28 days. The next registered nurse supervisory visit was 03/11/2025, 26 days. There was a registered nurse supervisory visit on 03/17/2025 and nothing else as of the review date of 04/09/2025, 23 days. CLINICAL RECORD 7: Hospice aide services were ordered for a frequency of three times weekly on 09/01/2024. There was a documented registered nurse supervisory visit on 01/23/2025 to 02/17/2025, 25 days. The next supervisory visit was on 03/11/2025, 22 days. CLINICAL RECORD 9: Hospice aide services were ordered for a frequency of three times weekly on 02/11/2025. There was a documented registered nurse supervisory visit on 02/17/2025 to 03/11/2025, 22 days. There was a documented registered nurse supervisory visit on 03/21/2025 to 04/09/2025, 19 days. CLINICAL RECORD 10: Hospice aide services were ordered for a frequency of three times weekly on 01/01/2025. There was a documented registered nurse supervisory visit on 01/01/2025 to 01/23/2025, 22 days. The next aide supervisory visit was 02/17/2025, 25 days. The next aide supervisory visit was 03/17/2025, 22 days. The next aide supervisory visit was 04/09/2025,23 days. An interview and joint clinical record review was conducted with the Administrator/DPCS on 04/09/2025 in which she replied that the “EMR (electronic medical record) might still be set for the covid supervisory visit frequency of monthly.””