Community Care and Hospice, LLC

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the comprehensive assessment update was completed no less frequently than every 15 days. Clinical Record 3: The patient elected the hospice benefit on 03/18/2024. Clinical record review revealed the Registered Nurse (RN) completed nursing visits and updates to the comprehensive assessment on 08/05/2024 and 08/23/2024, a total of 18 days between RN visits and 3 days outstanding. During an interview and joint clinical record review on 09/10/2024, the Administrator/Director of Patient Care Services stated the comprehensive assessment was not completed by the Registered Nurse every 14 days.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals 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 and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the individualized plan of care included patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 12/08/2023. The initial spiritual assessment completed by the Chaplain on 12/08/2023 included documentation of “Chaplain 1 time per month with 2 as needed for spiritual crisis.” The initial psychosocial assessment completed by the Social Work dated 12/11/2023 included documentation of “Social work 1 time per month with 3 as needed for social crisis.” The plan of care dated 12/08/2023 did not include goals and interventions related to the findings from the spiritual and psychosocial assessments. Clinical Record 10: The patient elected the hospice benefit on 04/23/2024. The initial nursing assessment dated 04/23/2024 included documentation that the patient had “Aspiration precautions.” The plan of care dated 04/23/2024 did not include goal(s) and intervention(s) for aspiration precautions. Clinical Record 11: The patient elected the hospice benefit on 01/23/2024. The initial nursing assessment dated 01/23/2024 included documentation that the patient had urinary incontinence. The plan of care dated 01/23/2024 did not include goal(s) and intervention(s) related to the patient’s urinary incontinence. During an interview and joint clinical record review on 09/10/2024, the Administrator/Director of Patient Care Services stated the plans of care did not reflect patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments.”

“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 [Registered Nurse] 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 3 (33%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse prepared patient-specific written care instructions for the Hospice Aide. Clinical Record 1: The patient elected hospice benefit on 12/08/2023. The plan of care dated 07/19/2024 included an order for the Hospice Aide (HA) to provide aide visits two times a week. Clinical record review revealed the patient was incontinent of urine and used depends for incontinence management. Review of the aide care plan revealed the aide was assigned to “measure urine output” and “empty urine collection bag.” The aide care plan did not include the care needs of the patient that was experiencing incontinence. During an interview while performing joint clinical record review on 09/10/2024, the Administrator/Director of Patient Care Services agreed the aide care plan did not accurately reflect the patient’s care needs.”

“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 clinical record review, personnel record review, and interview. In 1 of 3 (33%) clinical records reviewed with aide services provided, the agency did not ensure staff completed a competency assessment prior to providing services. Clinical Record 1: The plan of care dated 08/09/2024 included an order for hospice aide frequency of visits “2 times per week.” Clinical record review revealed the Licensed Vocational Nurse (LVN) (Personnel Record 2) completed three hospice aide visits dated 08/13/2024, 08/16/2024, and 08/20/2024. During a joint review of the record and interview on 09/11/2024, the Administrator/Director of Patient Care Services stated “The LVN covered the 3 aide visits, to meet the frequency order, while the aide was on vacation.” Review of the LVN personnel record revealed no documented evidence of a competency assessment for the aide tasks provided. The Administrator/Director of Patient Care Services confirmed the LVN personnel record did not include an aide competency assessment.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I, and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient transferred to another hospice agency, the agency did not ensure the discharge summary was forwarded to the receiving agency. Clinical Record 14: The patient elected hospice benefit on 05/19/2024 and elected to transfer to another hospice on 06/18/2024. The Registered Nurse documented in the clinical note dated 06/18/2024, “The plan of care, certificate of terminal illness, medication list, and discharge summary were forwarded to the receiving agency.” Clinical record review revealed no documented evidence to confirm the discharge summary was sent to the receiving hospice. During an interview and joint clinical record review on 09/10/2024, the Administrator/Director of Patient Care Services stated there was no documentation to confirm the discharge summary was forwarded to the receiving agency.”