Lucent Hospice

“Upon patient record review, 1 of 6 (Patient #3) 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. Patient #3: There was no evidence of an initial bereavement assessment being completed within 5 days.”

“Upon patient record review, 2 of 6 (Patient #4, 5) 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 #4: The patient was admitted on 08/11/25. The nursing visits are incomplete with no evidence of RN visits being completed every 15 days. There is no evidence of a comprehensive assessments being done between admission and 09/12/25. The entered visits contained a KPS score, a mid arm circumference, and an aide supervision. There are no other vital signs obtained and there was not an assessment of symptoms or body systems. Patient #5: The patient was admitted on 08/07/25. The nursing visits are incomplete with no evidence of RN visits being completed every 15 days. There is no evidence of comprehensive assessments being done between admission and 09/12/25. The entered visits contained a KPS score, a mid arm circumference, and an aide supervision. There are no other vital signs obtained and there was not an assessment of symptoms or body systems.”

“Upon patient record review, 2 of 6 (Patient #4, 5) 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 #4: The patient was admitted on 08/11/25. The nursing visits are incomplete. There is no evidence of a comprehensive nursing assessment being done between admission and 09/12/25. The SN visits contained a KPS score, a mid arm circumference, and an aide supervision only. There are no other vital signs obtained and there was not an assessment of symptoms or body systems. Patient #5: The patient was admitted on 08/07/25. The nursing visits are incomplete. There is no evidence of a comprehensive nursing assessment being done between admission and 09/12/25. The SN visits contained a KPS score, a mid arm circumference, and an aide supervision only. There are no other vital signs obtained and there was not an assessment of symptoms or body systems.”

“Upon patient record review, 3 of 6 (Patient #1, 2, 4) 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. Patient #1: The patient is on service for cerebral infarct and has co morbidities of heart disease and diabetes. There are no interventions or goals related to patient primary diagnosis of cerebral infarct. The patient is taking metformin. There are no interventions or goals related to diabetes. The patient is on Aspirin. There are no interventions or goals related to bleeding or the use of anticoagulants. The patient is on a pureed diet with Thick-It and 1:1 feeding. The pureed diet is evident however there are no interventions or goals related to thickened liquids or the need for a one to one feed. The patient was admitted with stage 3 coccyx/sacral wound. There are no interventions or goals for the wound care and orders. The patient is seeing SC monthly however there are no spiritual interventions or goals in the plan of care. Patient #2: The patient is on service for Prostate cancer. There are no interventions or goals related to primary diagnosis of cancer. The patient is on Eliquis with no interventions or goals related to use of anticoagulants. There are no interventions or goals for pain, despite patient being prescribed opiates for pain. The patient was admitted with a stage 2 wound to bilateral buttocks however there are no interventions or goals related to wound care orders. Patient was admitted on a 7 day course of antibiotics for an active UTI, however there are no interventions or goals regarding active UTI. Patient 4: The patient is to see spiritual care monthly. There are no interventions or goals related to spiritual care.”

“Upon patient record review, 3 of 6 (Patient #1, 2, 3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The patient has a stage 3 coccyx/sacral wound as well as an unstageable wound to left upper back with slough. The orders for both reads cleanse with NS and pat dry. Apply triple antibiotic cream and cover with bordered silicone dressing, change dressing q3 days and prn soilage. The order is incomplete and does not specify who will change the dressing. Patient #2: The patient has a stage 2 pressure wound on bilateral buttocks. Cleanse with cleanser and pat dry. Apply triple antibiotic cream and cover with bordered silicone dressing every 3 days and prn soilage. The order is incomplete and does not specify who will change the dressing. Patient #3: The patient was ordered to have wound care on right upper chest incision. Order reads cleanse with wound cleanser, pat dry. Apply triple antibiotic cream and cover with a “non adherent dressing gauze island dressing twice weekly and prn soilage.” The dressing needs to be clarified and the order does not specify who is to cleanse the dressing.”

“Upon patient record review, 3 of 6 (Patient #1, 2, 3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The patient is receiving wound care. The supply/DME list does not include wound supplies for wound care. Patient #2: The patient is receiving wound care. The supply/DME list does not include wound supplies. The patient has an indwelling foley, however, the supply list does not include foley supplies. Patient #3: The patient has a colostomy. Colostomy supplies are not included on the supply/DME list.”

“Upon patient record review 4 of 6 (Patient #1, 2, 3, 4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: Patient was admitted on 09/09/25. Aide services were ordered for 1 week 1, then twice weekly. There is no evidence of aide visits in the record. Patient #2: Patient admitted on 08/27/25. Aide services were ordered for 1 week 1, then twice weekly. There is no evidence of any aide visits in the record. Patient #3: Patient admitted 08/18/25. Aides were ordered twice weekly. On 08/20/25, aide services were increased to 3 times weekly. There are only 2 aide visits in the record for 08/20/25 and 09/12/25. Patient #4: Patient admitted 08/11/25. Aide services ordered for twice weekly. There were 3 visits the week of 08/10/25 without an order for an extra visit. The week of 09/07/25, there is no evidence of any visits being completed.”

“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. The hospice administrator failed to ensure oversight of all core services, as required by regulation. The hospice did not maintain plans of care for each patient that reflected patient and family goals and identified interventions based on the initial comprehensive assessments for the palliation and management of the terminal illness and related conditions. In addition, the hospice did not provide individualized plans of care as evidenced by not updating the plan of care with patient’s progress towards outcomes, completing nursing assessments, providing continuous assessments of each patient. Multiple aide visits were absent in the records showing that there was no adherence to ordered frequencies set forth in the aide plan of care.”

“Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #14 - The personnel file of the MSW showed a contracted individual (1099), not an actual employee (W-4), the status change occurred on 08/06/23 at the request of the MSW. There was no evidence of a waiver in place prior to the transition.”

“Upon patient record review, 2 of 14 (Patient #7,14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #7 - The patient’s plan of care initiated on 06/27/25, noted an intervention of Miralax as needed for bowel management. The medication profile did not include a diluent for that medication. Patient #14 - Patient’s medication profile showed Miralax was initiated daily for constipation. There was no evidence of a diluent added for that medication.”

“Upon patient record review, 2 of 14 (Patient #1,6) 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. Patient #1 - The nursing comprehensive dated 06/15/23, stated “family was at high risk for bereavement” related to the patients quick decline in health status. The medical record had no evidence of a complete bereavement assessment and there was no primary bereaved outlined. Patient #6 - The medical record showed no evidence of an initial bereavement to include the primary bereaved and the other components of that assessment in the nursing comprehensive, social work, or spiritual care comprehensive assessments.”

“Upon patient record review, 8 of 14 (Patient #2,3,4,6,7,8,9,11) 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. Patient #2 - The patient medication profile indicated patient is taking a daily dose of Eliquis. There is no evidence of problems, goals or interventions related to the bleeding risk of this medication. Patient #3 - The patient medication profile indicated patient is taking a daily dose of Xarelto. There is no evidence of problems, goals or interventions related to the bleeding risk of this medication. The profile also had Zofran as needed for nausea or vomiting which was not outlined in the plan of care with problems, goals or interventions. Patient #4 - The nursing comprehensive dated 09/19/24 indicated patient had a pacemaker - the plan of care did not include problems, goals or interventions. The same comprehensive also indicated patient was incontinent of bowel and bladder with no problems, goals or interventions related to incontinence. Patient #6 - The patient medical record showed no plan of care outlining any problems, goals, or interventions outlining the overall care the patient is receiving. This was corrected onsite with the initiation of the patient’s plan of care. Patient #7 - The patient nursing comprehensive dated 06/27/25 outlined the patient was experiencing some shortness of breath and utilizing a nebulizer. Patient was also utilizing Zofran as needed for nausea or vomiting. There was no evidence of goals, problems or interventions related to shortness of breath or nausea/vomiting. Patient #8 - The patient’s medical record had advanced directives which indicated patient chose to receive life sustaining measures. There was no evidence of problems, goals or interventions related to the full code status. Patient #9 - The patient’s nursing comprehensive dated 06/25/25, indicated patient is utilizing oxygen and a nebulizer for shortness of breath. There was no evidence of problems, goals or interventions related to shortness of breath. Patient #11 - The nursing comprehensive dated 11/23/24 documented the patient at a 10 on the Braden skin scale. There was no evidence of problems, goals or interventions related to poor skin integrity.”

“Upon patient record review, 7 of 14 (Patient #1,2,3,4,6,10,11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs Patient #1 - The patient has a stage 3 wound to the left heel. There was no evidence of wound care supplies on the patient supply list. There was also documentation that listed patient to be incontinent of bowel and bladder and utilizing incontinent supplies. These supplies were not listed on the supply list. The nursing comprehensive also noted patient to be utilizing oxygen at 2L via nasal cannula which was not listed on the patient supply list. Patient #2, 4 - The patient is on a nebulizer and utilizing oxygen for relief of shortness of breath. The supplies needed were not listed on the patient supply list. The medical record also indicated that the patient was incontinent of bowel and bladder. There was no evidence that incontinent supplies were listed on patient’s supply list. Patient #3, 6, 10, 11 - The patient is utilizing a nebulizer as well as oxygen for the treatment of shortness of breath. The supplies needed were not included on the patient supply list.”

“Upon patient record review, 9 of 14 (Patient #1,2,3,4,6,7,8,9,10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patients #1, 2, 3, 4, 7, 8, 9 - There were no RN updates or documented collaboration on the IDG meeting dates: 07/02/25, 07/17/25 and 07/30/25. All of the IDG notes were blank. Patient #6 - There were no RN updates or documented collaboration on the IDG meeting dates: 07/17/25 and 07/30/25. All of the IDG notes were blank. Patients #2, 3, 4, 9, 10 - The IDG meeting on 07/30/25, there was no evidence of collaboration between the spiritual care coordinator and the members of the IDG. There was no evidence of a plan of care update or change in the patients’ plan of care. The IDG note section by the SCC was blank.”

“Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #11 - Upon record review, it was noted that patient expired on 12/18/24. There was no evidence of a bereavement plan of care in place. There was no evidence of timely letters or mailings sent to the bereaved. Patient #12 - Upon record review, it was noted that patient expired on 07/30/25. There was no evidence of a bereavement plan of care in place.”

“Upon patient record review 2 of 14 (Patient #9,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #9 - The medical record showed evidence of a plan of care and a physician order for aide frequencies of two times per week. There was no evidence of aide visits during the week of 07/06/25 - 07/13/25. Patient #12 - The medical record showed evidence of a plan of care and a physician order for aide frequencies of two times per week. The week of 07/20/25-07/27/25, aide visits occurred 07/22/25, 07/23/25, and 07/24/25. There was no evidence of an order for the extra aide visit.”

“Upon patient record review 9 of 14 (Patient #2,4,6,7,9,10,11,12,13) did not have evidence documentation in the patient record that a Registered Nurse made 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 to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient#2 - There is an order for aide visits to be completed two times per week. Supervisory visits were conducted on 05/14/25, 06/11/25, and 07/07/25. Patient#4, 10, 13 - There is an order for aide visits to be completed two times per week. The medical record showed supervisory visits completed every sixty days. Patient #6 - There is an order for aide visits to be completed five times per week. There was no evidence of any completed RN supervisory visits. Patient #7 , 9, 11, 12 - There is an order for aide visits to be completed two times per week. There was no evidence of any aide supervisory visits completed.”

“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. The hospice administrator failed to ensure oversight of all core services, as required by regulation, with the medical social worker working as a contract personnel since August 2023. The hospice did not maintain plans of care for each patient that reflected patient and family goals and identified interventions based on the initial comprehensive assessments for the palliation and management of the terminal illness and related conditions. The IDG, in collaboration with the attending physician, did not consistently review and revise the plan of care at least every 15 days, as required, with evidence of missed IDG meeting dates in July by both the RN and the spiritual care provider. Additionally, for many patients, the RN did not conduct on-site supervisory visits of the hospice aide at least every 14 days to assess the quality of care and services provided by the hospice aide.”

“Upon patient record review, 1 of 5 (Patient #1) 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. Patient 01: The patient was admitted on 9/25/23, the initial bereavement assessment was completed on 11/1/23.”

“Upon patient record review, 2 of 5 (Patient #1, 2) 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. Patient 01: The patient was admitted on 9/25/23 and has orders for Xarelto 20mg daily, the plan of care does not include bleeding precautions. Patient 02: The patient was admitted on 4/1/23 and remains a full code. The plan of care does not include a problem statement with interventions and goals to address the code status as identified by the SW.”

“Upon patient record review, 1 of 5 (Patient #3) 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. Patient 03: The patient receives monthly visits from the spiritual care counselor and the MSW, there are no problem statements with interventions and goals for the SCC and MSW services. The patient received orders on 8/14/23 for Physical Therapy, consult/evaluate/treat, the plan of care was not updated to include interventions and goals for the PT services.”

“Upon patient record review, 3 of 5 (Patient #2, 4, 5) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient’s clinical information and provide written documentation that it is anticipated that the patient’s life expectancy is 6 months or less. Patient 02: The certificate of terminal illness for the benefit period starting 6/13/22, does not include a physician narrative statement that includes subjective and objective information. The certificate of terminal illness for the benefit period starting 11/10/23 does not include a physician narrative statement that includes subjective and objective information. Patient 04: The certificate of terminal illness for the benefit period starting 5/11/23, does not include a physician narrative statement that includes subjective and objective information. The certificate of terminal illness for the benefit period starting 7/4/23, does not include a physician narrative statement that includes subjective and objective information. The certificate of terminal illness for the benefit period starting 9/2/23, does not include a physician narrative statement that includes subjective and objective information. Patient 05: The certificate of terminal illness for the benefit period starting 10/18/23, does not include a physician narrative statement that includes subjective and objective information.”