Rx Staffing Hospice Care

“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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the organization did not ensure the comprehensive assessment included an initial bereavement assessment. Clinical Record 2: The patient elected the hospice benefit on 10/02/2023. Review of the clinical record revealed no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. During an interview and review of the clinical record on 11/01/2024, the Clinical Quality Assurance Nurse stated that the patient’s spouse refused spiritual care and bereavement services during the first five days of services and the bereavement assessment was not assigned to another clinician to complete.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by, the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with documented continuous care level of care, the organization did not ensure hospice care and services provided to the patient and family followed the plan of care established by the hospice Interdisciplinary Group [IDG]. Clinical Record 4: The patient was admitted to hospice services on 12/05/2023 with diagnoses of Alzheimer’s Disease, adult failure to thrive, diastolic congestive heart failure, and right hip and sacral stage 4 pressure ulcers. Review of the clinical record revealed the patient’s Registered Nurse Case Manager began documenting hourly entries on a visit note labeled as Continuous Care on 12/11/2024. The hourly entries ended on 12/12/2024 with the patient’s death. There was no documented evidence in the clinical record that the physician ordered continuous care services and no documented evidence that the plan of care was updated for continuous care services. During an interview and review of the clinical record on 11/01/2024, the Clinical Quality Assurance Nurse confirmed the patient’s plan of care was not updated by the hospice IDG to change the patient’s level of care from routine to continuous care on 12/11/2024. The nurse stated, “There is no physician’s order to update the plan of care to continuous care, but the RN provided and documented continuous care.””

“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 10 (10%) clinical records reviewed with nursing supervision required, the organization did not ensure the Registered Nurse (RN) provided nursing supervisory assessments as required by agency policy. The organization’s policy on nursing supervision revised 09/15/2021 required in part, “Licensed Vocational/Practical Nurses shall have a current LVN/LPN license, at least one (1) year experience as a licensed nurse, and shall work under the supervision of a Registered Nurse. Supervision shall occur no less than every 30 days.” Clinical Record 5: The patient elected the hospice benefit on 02/05/2024 with benefit period 4 effective 10/04/2024 to 11/30/2024. Clinical record review revealed the RN documented an LVN supervisory assessment on 09/10/2024. The next LVN supervisory assessment was dated 10/28/2024, a total of 48 days and 18 days outstanding. During an interview and review of the clinical record on 11/01/2024, the Clinical Quality Assurance Nurse confirmed the RN completed the LVN supervisory assessments 48 days apart.”

“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 3 of 11 (27%) clinical records reviewed with aide services provided for more than 14 days, the organization did not ensure the Registered Nurse (RN) documented aide supervisory assessments no less frequently than every 14 days. Clinical Record 2: The patient elected the hospice benefit on 10/02/2023. Clinical record review revealed aide services were effective 10/06/2023. The RN documented an aide supervisory assessment on 10/12/2023 and the next aide supervisory assessment was dated 10/27/2023, a total of 15 days and 1 day outstanding. Clinical Record 5: The patient elected the hospice benefit on 02/05/2024. Clinical record review revealed aide services were effective 10/04/2024. The RN documented an aide supervisory assessment on 09/24/2024 and the next aide supervisory assessment was dated 10/22/2024, a total of 28 days and 14 days outstanding. Clinical Record 6: The patient elected the hospice benefit on 06/11/2024. Clinical record review revealed aide services were effective 09/09/2024. The RN documented an aide supervisory assessment on 09/17/2024 and the next aide supervisory assessment was dated 10/02/2024, a total of 15 days and 1 day outstanding. During an interview and review of the clinical records on 11/01/2024, the Clinical Quality Assurance Nurse confirmed the RN did not document aide supervisory assessments every 14 days.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The organization did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent of the total patient care hours of all paid hospice employees and contract staff. During a concurrent interview and review of the agency binder titled Volunteer Program with the Administrator/Volunteer Coordinator on 11/01/2024, it was revealed that the organization did not provide volunteer services in 2023 and in 2024. The Administrator provided his documented efforts to recruit volunteers after the end of the public health emergency in May of 2023, and explained they were not successful until April of 2024 when two volunteers were hired. The calculation of volunteer time cost savings presented by the Administrator calculated from April 2024 through October 2024 was 0.6%. During a concurrent interview and review of the binder titled Volunteer Program with the Administrator/Volunteer Coordinator on 11/01/2024, it was revealed that the organization did not provide volunteer services at all in 2023 and in 2024 did not provide volunteer services that at minimum equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Administrator revealed that his documented efforts to recruit volunteers after the end of the public health emergency in May of 2023, were not successful until he hired two volunteers in April of 2024. The calculation of volunteer time cost savings presented by the Administrator calculated from April 2024 through October 2024 was 0.6%.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed for patients that reside in an SNF [Skilled Nursing Facility], the organization did not ensure the hospice plan of care specified which provider was responsible for performing the functions agreed upon and included in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 10/02/2023. The patient resided in an SNF. The hospice plan of care did not identify which provider was responsible for performing care and services agreed upon and included in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 06/13/2024. The patient resided in an SNF. The hospice plan of care did not identify which provider was responsible for performing care and services agreed upon and included in the plan of care. Clinical Record 11: The patient elected the hospice benefit on 08/16/2024. The patient resided in an SNF. The hospice plan of care did not identify which provider was responsible for performing care and services agreed upon and included in the plan of care. Clinical Record 14: The patient elected the hospice benefit on 09/28/2024. The patient resided in an SNF. The hospice plan of care did not identify which provider was responsible for performing care and services agreed upon and included in the plan of care. During the daily wrap-up conference on 10/31/2024, the Administrator stated, “Our contract with the SNFs includes an addendum listing the delineation of responsibilities between us and them, but I agree that our patient plans of care do not include whether it is the hospice, the SNF, or both that are specifically providing specific functions included in individual patient plans of care.””