Crossroads Hospice Vallejo

“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 associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, clinical record review, interviews, and review of findings with the Administrator and the Director of Patient Care Services which revealed the following issues with Interdisciplinary Group assessment and the development and implementation of patients’ interdisciplinary care plans: Failure to ensure the Registered Nurse member of the Interdisciplinary Group ensured the continuous assessment of the patient’s needs [HCPC.19.I/L540]; Failure to ensure the individualized plan of care included treatments necessary to meet the needs of the patient [HCPC.21.I/L549]; and Failure to ensure the patient’s individualized written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments [HCPC.21.I/L545]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary Group, Care Planning, and Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving home health care service from the agency.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, clinical record review, interviews and review of findings with the Administrator and Director of Patient Care Services, which revealed the following issues regarding Hospice Aide services: Failure to ensure the Hospice Aide provided services as ordered in the plan of care [HCDT.16.I/L626]; Failure to ensure the Hospice Aide documented communication and coordination with the Registered Nurse when there were deviations from the written aide care plan [HCDT.18.I/L628]; and Failure to ensure the Registered Nurse documented supervision of the hospice aide every 14 days [HSRM.25.I/L629]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving home health care service from the agency.”

“It is required that the drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by document review, clinical record review, document review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s medication profile was updated to include new medications. Agency policy No. 2-004 Medication Profile, dated May 2023, stated in part, “Medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.” Clinical Record 11: The patient elected the hospice benefit on 07/28/2023 with a terminal diagnosis of neoplasm of the craniopharyngeal duct. The Registered Nurse (RN) documented on 03/01/2024 that the Baclofen [muscle relaxant] regimen had been changed to Tizanidine [muscle relaxant] to address the patient’s pain related to contractures. The Baclofen pain regimen had become less effective, and the patient’s pain was documented at a 4 on a scale of 1-10. On 03/08/2024, the RN documented “Pt on Tizanidine a muscle relaxant. Pain a 0.” The Licensed Vocational Nurse documented on 03/12/2024 that “PCG [primary caregiver] reports patient had experienced adverse reactions to Tizanidine...reported findings to RNCM [Registered Nurse Case Manager]. Medication discontinued. Patient returned to using Baclofen.” Clinical record review revealed no documented evidence that the medication profile was updated to include Tizanidine. The clinical record contained no evidence of physician orders, to discontinue Baclofen, add Tizanidine, discontinue Tizanidine, and restart Baclofen. Review of documentation from Interdisciplinary Group Meeting dated 03/07/2024 revealed no documented evidence of an update from the RN regarding the initiation of Tizanidine and the patient’s related pain assessment. During an interview and joint record review on 03/20/2024, the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2) confirmed that no order was entered in the clinical record for Tizanidine.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of 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. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the initial bereavement assessment was completed as part of the comprehensive assessment. Agency policy No. 1-021 Bereavement Assessment, dated May 2023, stated in part, “On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment.” Clinical Record 1: The patient elected the hospice benefit on 06/22/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the Social Worker (SW) documented that the family requested to delay the initial social services assessment until 06/29/2023. The initial bereavement assessment was completed during the SW visit on 06/29/2023 and was not completed as part of the comprehensive assessment. The Registered Nurse completed the comprehensive assessment on 09/13/2023 but did not document an initial bereavement assessment. Clinical Record 4: The patient elected the hospice benefit on 09/13/2023, with a terminal diagnosis of hypertensive heart disease. Clinical record review revealed the Social Worker documented that the family requested to delay the initial social services assessment until 10/20/2023. The initial bereavement assessment was completed during the SW visit on 10/20/2023 and was not completed as part of the comprehensive assessment. The Registered Nurse completed the comprehensive assessment on 09/13/2023 but did not document an initial bereavement assessment. Clinical Record 7: The patient elected the hospice benefit on 10/11/2023, with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the Social Worker completed the initial bereavement assessment on 10/17/2023, six days after the patient’s admission to hospice. During an interview and joint clinical record review with the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2), it was confirmed that these patient’s initial bereavement risk assessments were performed after the initial five-day regulatory period for the comprehensive assessment.”

“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. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the registered nurse ensured continuous assessment of the patient’s needs. Agency policy No. 9-019 Nursing Care, dated May 2023, stated in part, “A hospice registered nurse will be assigned as the Case Manager for each patient. Duties will include the responsibility for coordination of care and fostering communication between the patient and the interdisciplinary group. The Case Manager will assure that the components of the plan of care are established and implemented by the interdisciplinary group. The hospice registered nurse...participates in the comprehensive assessment and ongoing updates of the comprehensive assessments. Licensed practical/vocational nurses will supplement the nursing care needs of the patient as provided by the registered nurse; this may include ...assisting the registered nurse in carrying out the plan of care.” Clinical Record 11: The patient elected the hospice benefit on 07/28/2023 with a terminal diagnosis of neoplasm of the craniopharyngeal duct. Clinical record review revealed the Licensed Vocational Nurse (LVN) documented on the 01/10/2024 nursing visit note, the patient “has dried blister to the sole of right foot. Wound cleansed with wound cleanser, patted dry, iodine applied.” On the nursing visit note dated 01/26/2024, the Registered Nurse (RN) documented the patient had a stage 2 wound to the right lateral foot and a stage 2 wound on the right hip. Review of nursing visit notes dated 01/30/2024, 02/06/2024, 02/09/2024, 02/16/2024, 02/20/2024, 02/23/2024, 02/27/2023, 03/01/2024, 03/05/2024, and 03/08/2024 revealed no documented evidence of wound assessment or measurement. On the 03/12/2024 nursing visit note, the LVN documented a stage 3 wound on the right outer foot measured 0.5cm x 0.5cm x 0.5cm, had purulent drainage, and was treated with Medihoney and optifoam. A stage 2 wound to the right hip contained a small amount of bloody drainage but no measurement of the wound was recorded. The hospice nurse did not provide continuous assessment of the patient’s wounds. Clinical Record 13: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of pleural effusion. The RN documented on the comprehensive assessment dated 02/27/2024 a stage 3 wound to the buttocks, but the patient refused assessment of the wound. The RN documented a stage 3 wound to the left foot that measured 1cm x 2cm x 0.1cm. The nurse documented both wounds were being cleaned with wound cleanser, patted dry with gauze, Medihoney applied and covered with calcium alginate, and secured with a foam dressing. As of the date of record review on 03/20/2024, the clinical record contained no documented evidence of an assessment and measurement of the buttocks wound, and no continued assessment or measurement of the foot wound after 02/27/2024. The hospice nurse did not provide continuous assessment of the patient’s wounds. During joint record reviews and interviews on 03/19/2024, 03/20/2024, and 03/21/2024, the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2) confirmed the clinical records did not include continuous assessment and documentation of wounds.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the patient’s individualized written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Agency policy No. 9-017 Plan of Care, dated May 2023, stated in part, “The care provided to the patient must be in accordance with the plan of care. The plan will focus on identified problems, goals, and interventions.” Clinical Record 3: The patient elected the hospice benefit on 01/31/2024 with a terminal diagnosis of congestive heart failure. The Registered Nurse (RN) documented on the initial comprehensive assessment dated 01/31/2024 that the patient only ate pureed foods, experienced episodes of dysphagia [difficulty swallowing] when swallowing liquids and required all liquids to be thickened. The plan of care dated 01/31/2024 did not include planned interventions for the patient’s assessed risk of aspiration, need for pureed diet, thickened liquids, and dysphagic episodes. Clinical Record 6: The patient elected the hospice benefit on 08/07/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the Licensed Vocational Nurse documented on 12/14/2024, the patient was sent to the emergency room and diagnosed with a urinary tract infection and medications were ordered. A physician order dated 12/14/2024 included an order for Cephalexin 500mg by mouth four times a day for 10 days for a urinary tract infection. The plan of care did not include planned interventions related to the patient’s diagnosed urinary tract infection. During joint clinical record review and interviews on 03/19/2024, 03/20/2024, and 03/21/2024, the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2) confirmed that the patients’ plans of care were not updated with planned interventions based on problems identified by the nurse in the initial and updated comprehensive assessments.”

“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 drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 clinical records reviewed, the agency did not ensure the individualized plan of care included treatments necessary to meet the needs of the patient. Agency policy No. 9-017 Plan of Care, dated May 2023, stated in part, “The care provided to the patient must be in accordance with the plan of care.” Agency policy No. 1-036 Interdisciplinary Group Meeting, dated May 2023, stated in part “It will note changes, response to treatment, and progress toward targeted outcomes, which may include pharmacotherapeutic effectiveness of symptom management outcomes.” Clinical Record 3: The patient elected the hospice benefit on 01/31/2024 with a terminal diagnosis of congestive heart failure. The Registered Nurse (RN) documented on the 02/16/2024 nursing visit note, that the patient had a stage 1 wound to the coccyx that was unopened, and a new dressing was placed. On the 02/23/2024 nursing visit note the RN documented the coccyx wound had progressed to a stage 2 and there were 2 small wounds to the coccyx area “one being about 3 cm and the other about 5cm.” The wounds were dressed with zinc paste and “DSD [dry see dressing].” The RN documented on the 02/28/2024 nursing note, the coccyx wounds had closed but continued dressing the wounds with zinc oxide and “DSD.” The clinical record contained no documented evidence that a wound care order was obtained for wound care provided to the coccyx wounds. Clinical Record 13: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of pleural effusion. The RN documented on the 02/27/2024 comprehensive assessment that the patient had a stage 3 wound to the left foot wound that measured 1cm x 2cm x 0.1cm and a stage 3 wound to the left buttock. The RN documented that both wounds were treated by cleaning the wound sites with wound cleanser, patted dry with gauze, applied Medihoney, covered with calcium alginate, and secured with a foam dressing. On 02/29/2024, the Licensed Vocational Nurse (LVN) documented spouse “provided wound care to buttocks, SN [skilled nurse] provided wound care to foot. Pt [patient] tolerated well.” The RN on the 03/05/2024 nursing note that “Patient with wound care needs to coccyx and left later foot. Left lateral foot wound associated with significant pain management needs.” The LVN documented on the 03/07/2024 visit note that the patient tolerated the wound care provided well. The clinical record contained no documented evidence that wound care orders were obtained for the patient’s left foot wound and buttock wound. During a joint clinical record review and interviews on 03/19/2024, 03/20/2024, and 03/21/2024, the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2) confirmed that the patients’ plans of care were not updated with the treatments necessary to care for the patients’ wounds. There was confirmation via internal communication that the Administrator could provide, but the information had not been documented in the clinical records. The Administrator agreed that the orders needed to be documented.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed with Licensed Vocational Nurse (LVN) provided visits to the patient and with hospice services provided for more than 30 days, the agency did not ensure that the Registered Nurse (RN) documented supervision of the LVN at least monthly as required by agency policy. Agency policy No. 1-030 Supervision, dated May 2023, stated in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services.” Clinical Record 10: The patient elected the hospice benefit on 11/15/2023 with a terminal diagnosis of Parkinson’s disease. The plan of care dated 11/15/2023 included a physician order for nurse visit frequency once a week. Clinical record review revealed the RN completed an LVN supervisory visit on 02/01/2024 and the next supervisory visit was dated 03/14/2024, 42 days after the supervisory visit dated 02/01/2024 and 12 days outstanding. The RN did not provide LVN supervisory visits monthly as required by agency policy. During an interview and joint clinical record review on 03/20/2024, the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2) confirmed that a gap did exist in LVN supervision by the RN.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 4 of 14 (29%) clinical records reviewed with hospice aide services provided, the agency did not ensure that the aide provided the services as ordered in the plan of care. Agency policy No. 9-020 Hospice Aide Services, dated May 2023, stated in part that “Hospice aides will document care provided in accordance with the hospice aide assignment.” Clinical Record 8: The patient elected the hospice benefit on 01/14/2024 with a terminal diagnosis of Alzheimer’s disease. The hospice aide care plan dated 01/24/2024 assigned the aide the tasks of complete shower every visit and shaving the patient once a week. The hospice aide documented on the visit notes dated 02/19/2024, 02/23/2024, 03/11/2024, and 03/15/2024 the patient refused shave. On the aide visit note dated 03/08/2024, the hospice aide documented a complete bed bath was provided instead of the shower that was assigned and on the 03/15/2024 visit note the aide documented a partial bath was completed. The hospice aide did not provide tasks/services to the patient as assigned on the aide care plan. Clinical Record 11: The patient elected the hospice benefit on 07/28/2023 with a terminal diagnosis of neoplasm of the craniopharyngeal duct. The plan of care dated 08/02/2023 included an order for the hospice aide frequency of visits to be twice a week. Clinical record review revealed from 01/22/2024 to 03/08/2024 the hospice aide provided three visits per week. Clinical record review revealed no documented evidence of a physician order to increase the aide visit frequency and no documentation that the Interdisciplinary Group (IDG) was aware of the increase frequency of visits by the hospice aide. The hospice aide care plan dated 01/24/2024 assigned the aide the tasks of assist to dress, complete bed bath, comb hair, foot care, peri care, shampoo hair, skin care, oral hygiene/denture care, nail care, check pressure areas, nail care, and record date of last bowel movement. On the aide visit note dated 01/28/2024 the aide did not document the date of the last bowel movement. On the aide visit note dated 02/01/2024 the aide left the following tasks unchecked indicating not completed, oral hygiene and nail care. The aide did not document that nail care was completed for the aide visits dated 02/04/2024, 02/06/2024, 02/08/2024, 02/17/2024, and 02/18/2024.The aide did not document that oral hygiene, nail care, and shampoo were completed for the aide visits dated 02/20/2024 and 02/22/2024. The hospice aide documented on the visit notes dated 02/26/2024, 02/28/2024, 03/01/2024, 03/04/2024, 03/06/2024, and 03/08/2024, the patient refused shampoo, oral hygiene, nail care, skin care, and comb hair. The hospice aide did not provide tasks/services to the patient as assigned on the aide care plan. Clinical Record 17: The patient elected the hospice benefit on 08/03/2024, with a terminal diagnosis of Parkinson’s disease. The hospice aide care plan dated 11/01/2023 assigned the aide the tasks of complete shower, shampoo, peri care, foot care, oral hygiene/dental care, comb hair, check pressure areas, skin care, nail care, and record the date of the patient’s last bowel movement (BM). On the visit notes dated 11/07/2023 and 11/14/2023 the aide did not document foot care, oral hygiene, comb hair, skin care, and nail care, indicating these tasks were no completed during the visits. The aide documented on the 01/02/2024 visit note “N/A” [not applicable] for the shower task. The aide documented on the 01/05/2024 and 01/09/2024 visit notes a complete bed bath was provided. The hospice aide did not provide tasks/services to the patient as assigned on the aide care plan. Clinical Record 19: The patient elected the hospice benefit on 06/24/2023, with a terminal diagnosis of bladder cancer. The hospice aide care plans dated 06/24/2023 and 09/22/2023 assigned the aide the tasks of complete bed bath, peri care, foot care, shampoo, skincare, check for pressure areas, nail care, oral hygiene/denture care, assist in dressing, comb hair, and record the date of the last bowel movement (BM). On the aide visit notes dated 08/17/2024 and 08/19/2024 the aide did not document shampoo and nail care, indicating these tasks were not completed during the visit. On the aide visits dated 08/24/2023, 08/31/2023, 09/05/2023, 09/11/2023, 09/18/2023, 10/09/2023, and 10/11/2023 the aide did not document shampoo, oral hygiene, and nail care. On the aide visit notes dated 08/29/2024, 09/07/2024, 09/14/2024, and 10/11/2024 the aide did not document oral hygiene and nail care. The aide documented on the aide visit note dated 10/06/2023 the date of the patient’s last BM, no other tasks were marked as completed. The aide documented the patient was medicated for back pain and the caregiver did not want the patient disturbed, so a bath was refused. The aide documented on the aide visit note dated 10/14/2023 pressure areas checked and date of the last BM. The aide documented “Cg [caregiver] just wanted help with turning and repositioning and propping a pillow underneath.” The aide visit noted dated 10/15/2023 included documentation that pressure areas were checked and the date of last BM. The aide included a note “Cg only wanted me to help reposition the patient. [The patient] has been in a lot of pain.” The clinical record contained no documented evidence that the Registered Nurse was notified of the patient’s status or the patient/caregiver refusal of care. The hospice aide did not provide tasks/services to the patient as assigned on the aide care plan. During joint clinical record review and interviews on 03/19/2024, 03/20/2024, and 03/21/2024, the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2) confirmed that hospice aide documentation did not follow the aide care plan as written. There was no documentation in the clinical record that there was communication between the Hospice Aide and the Registered Nurse Case Manager.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by document review, clinical record review, and interview. In 5 of 14 (36%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide documented communication and coordination with the Registered Nurse when there were deviations from the written aide care plan. Agency policy, No. 9-020 Hospice Aide Services, dated May 2023, stated in part, “Hospice aides will document care provided in accordance with the hospice aide assignment. Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care.” Clinical Record 4: The patient elected the hospice benefit on 09/13/2023, with a terminal diagnosis of hypertensive heart disease. The hospice aide care plans dated 12/29/2023 and 03/11/2024 assigned the aide the tasks to assist in dressing, shampooing hair, comb hair, peri care, foot care, skin care, oral hygiene/denture care, nail care, complete shower, and check for pressure areas. The hospice aide documented on aide visit notes dated 02/26/2024 and 02/28/2024, the patient refused the tasks of shampooing hair, comb hair, skin care, oral hygiene, and nail care. The hospice aide documented on aide visit notes dated 03/01/2024, 03/04/2024, 03/06/2024, and 03/08/2024, the patient refused shampooing hair, comb hair, skin care, oral hygiene, foot care, and nail care. Clinical record review revealed no documented evidence that the hospice aide communicated or coordinated with the Registered Nurse and notified the nurse of the patient’s refusal of services. Clinical Record 8: The patient elected the hospice benefit on 01/14/2024 with a terminal diagnosis of Alzheimer’s disease. The hospice aide care plan dated 01/24/2024 assigned the aide the tasks of complete shower every visit and shaving the patient once a week. The hospice aide documented on the visit notes dated 02/19/2024, 02/23/2024, 03/11/2024, and 03/15/2024 the patient refused to be shaved. On the aide visit note dated 03/08/2024, the hospice aide documented a complete bed bath was provided instead of the shower that was assigned and on the 03/15/2024 the aide documented a partial bath was completed. Clinical record review revealed no documented evidence that the hospice aide communicated or coordinated with the Registered Nurse and notified the nurse of the patient’s refusal of services. Clinical Record 11: The patient elected the hospice benefit on 07/28/2023 with a terminal diagnosis of neoplasm of the craniopharyngeal duct. The hospice aide care plan dated 01/24/2024 assigned the aide the tasks of assist to dress, complete bed bath, comb hair, foot care, peri care, shampoo hair, skin care, oral hygiene/denture care, nail care, check pressure areas, nail care, and record date of last bowel movement. On the aide visit note dated 01/28/2024 the aide did not document the date of the last bowel movement. On the aide visit note dated 02/01/2024 the aide left the following tasks unchecked indicating not completed, oral hygiene and nail care. The aide did not document that nail care was completed for the aide visits dated 02/04/2024, 02/06/2024, 02/08/2024, 02/17/2024, and 02/18/2024. The aide did not document that oral hygiene, nail care, and shampoo were completed for the aide visits dated 02/20/2024 and 02/22/2024. The hospice aide documented on the visit notes dated 02/26/2024, 02/28/2024, 03/01/2024, 03/04/2024, 03/06/2024, and 03/08/2024, the patient refused shampoo, oral hygiene, nail care, skin care, and comb hair. Clinical record review revealed no documented evidence that the hospice aide communicated or coordinated with the Registered Nurse related to the aide services not provided and the patient’s refusal of services. Clinical Record 17: The patient elected the hospice benefit on 08/03/2024, with a terminal diagnosis of Parkinson’s disease. The hospice aide care plan dated 11/01/2023 assigned the aide the tasks of complete shower, shampoo, peri care, foot care, oral hygiene/dental care, comb hair, check pressure areas, skin care, nail care, and record the date of the patient’s last bowel movement (BM). On the visit notes dated 11/07/2023 and 11/14/2023 the aide did not document foot care, oral hygiene, comb hair, skin care, and nail care, indicating these tasks were not completed during the visits. The aide documented on the 01/02/2024 visit note “N/A” [not applicable] for the shower task. The aide documented on the 01/05/2024 and 01/09/2024 visit notes a complete bed bath was provided and not the shower that was assigned. Clinical record review revealed no documented evidence that the hospice aide communicated or coordinated with the Registered Nurse related to the aide services not provided and the patient’s refusal of services. Clinical Record 19: The patient elected the hospice benefit on 06/24/2023, with a terminal diagnosis of bladder cancer. The hospice aide care plans dated 06/24/2023 and 09/22/2023 assigned the aide the tasks of complete bed bath, peri care, foot care, shampoo, skincare, check for pressure areas, nail care, oral hygiene/denture care, assist in dressing, comb hair, and record the date of the last bowel movement (BM). On the aide visit notes dated 08/17/2024 and 08/19/2024 the aide did not document shampoo and nail care, indicating these tasks were not completed during the visit. On the aide visits dated 08/24/2023, 08/31/2023, 09/05/2023, 09/11/2023, 09/18/2023, 10/09/2023, and 10/11/2023 the aide did not document shampoo, oral hygiene, and nail care. On the aide visit notes dated 08/29/2024, 09/07/2024, 09/14/2024, and 10/11/2024 the aide did not document oral hygiene and nail care. The aide documented on the aide visit note dated 10/06/2023 the date of the patient’s last BM, no other tasks were marked as completed. The aide documented the patient was medicated for back pain and the caregiver did not want the patient disturbed, so a bath was refused. The aide documented on the aide visit note dated 10/14/2023 pressure areas checked and date of the last BM. The aide documented “Cg [caregiver] just wanted help with turning and repositioning and propping a pillow underneath.” The aide visit noted dated 10/15/2023 included documentation that pressure areas were checked and the date of last BM. The aide included a note “Cg only wanted me to help reposition the patient. [The patient] has been in a lot of pain.” The clinical record contained no documented evidence that the Registered Nurse was notified of the patient’s status related to pain or the patient/caregiver’s refusal of cares. During joint clinical record review and interviews on 03/19/2024, 03/20/2024, and 03/21/2024, the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2) confirmed the aides did not document that the Registered Nurse Case Manager was notified when the aide care plan interventions were not followed or when a change in the patient’s condition was noted. They stated that some education with the Aides needed to be accomplished.”

“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 document review, clinical record review, and interview. In 4 of 14 (29%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse documented supervision of the hospice aide every 14 days. Agency policy No. 1-037 Hospice Aide Supervisory Visits, dated May 2023, stated in part, “The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days. Supervisory visits and overall supervision will be documented in the clinical record.” Clinical Record 4: The patient elected the hospice benefit on 09/13/2023, with a terminal diagnosis of hypertensive heart disease. The plan of care dated 02/19/2024 included a physician order for aide frequency of visits twice a week. An interim physician order dated 02/26/2024 increased the aide visit frequency to three times a week. Clinical record review revealed the first aide visit was dated 01/03/2024 and the Registered Nurse (RN) completed the first aide supervisory visit on 01/19/2024, 16 days after the first aide visit and 2 days outstanding. The RN documented an aide supervisory visit on 02/02/2024 and the next aide supervisory visit was dated 03/01/2024, 28 days after the 02/02/2024 supervisory visit and 14 days outstanding. The RN did not provide aide supervisory visits no less frequently than every 14 days as required by agency policy. Clinical Record 6: The patient elected the hospice benefit on 08/07/2023 with a terminal diagnosis of senile degeneration of the brain. The plan of care dated 10/05/2023 included a physician order for aide frequency of visits twice a week. Clinical record review revealed the RN completed an aide supervisory visit on 12/19/2023 and the next supervisory visit was dated 01/04/2024, 16 days after the supervisory visit dated 12/19/2023 and 2 days outstanding. The RN documented an aide supervisory visit on 01/16/2024 and the next aide supervisory visit was dated 02/27/2024, 42 days after the 01/16/2024 supervisory visit and 28 days outstanding. The RN did not provide aide supervisory visits no less frequently than every 14 days as required by agency policy. Clinical Record 10: The patient elected the hospice benefit on 11/15/2023 with a terminal diagnosis of Parkinson’s disease. The plan of care dated 11/15/2023 included a physician order for aide frequency of visits twice a week. Clinical record review revealed the RN completed an aide supervisory visit on 01/11/2024 and the next supervisory visit was dated 02/11/2024, 21 days after the supervisory visit dated 01/11/2024 and 7 days outstanding. As of the date of record review on 03/20/2024, the RN had not documented an aide supervisory visit since the supervisory visit of 02/11/2024, a total of 42 days and 28 days outstanding. Clinical Record 17: The patient elected the hospice benefit on 08/03/2024, with a terminal diagnosis of Parkinson’s disease. The plan of care dated 08/11/2023 included a physician order for aide frequency of visits twice a week. Clinical record review revealed the RN completed an aide supervisory visit on 12/26/2023 and the next supervisory visit was dated 01/16/2023, 21 days after the supervisory visit dated 12/26/2023 and 7 days outstanding. During a joint clinical record review and interviews on 03/19/2024, 03/20/2024, and 03/21/2024, the Administrator (Staff 1) and the Director of Patient Care Services (Staff 2) confirmed that there were gaps in the documentation of the supervision of the hospice aide by the RN.”