Aasta Hospice

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed, the agency did not ensure documentation that reasonable efforts were made to facilitate visits by local clergy. Clinical Record 12: The patient elected the hospice benefit on 09/04/2024. The plan of care dated 09/04/2024 to 12/02/2024 included an order for Spiritual Counselor frequency of visits one (1) time per month. The Spiritual Counselor documented on the spiritual counseling visit dated 11/21/2024, the patient was requesting a priest to come and give communion, if possible. The clinical record contained no documented evidence that the priest was contacted about a possible visit to the patient. During an interview on 12/12/2024, the Administrator and the Director of Patient Services stated they did not know if the Spiritual Counselor had made any follow-up.”

“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; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse completed supervisory visits for the Hospice Aide no less frequently than every 14 days. Agency policy No. 2-041.1 Internal Control Systems/Accountabilities, required in part, “Aide supervisory visits are performed and documented every 14 days.” Clinical Record 12: The patient elected the hospice benefit on 09/04/2024. The plan of care dated 09/04/2024 to 12/02/2024 included an order for the hospice aide to provide services twice per week. The clinical record included documentation that the patient received aide services as ordered. Clinical record review revealed the Registered Nurse completed an aide supervisory visit on 11/10/2024 and the next aide supervisory visit was dated 11/25/2024, a total of 15 days and one day outstanding. During an interview on 12/12/2024, the Director of Patient Care Services stated that they try so very hard to stay on top of it, they will continue with additional education to clinical staff.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary; and the patient’s record, if requested. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed with live discharge, the agency did not ensure the discharge summary was completed and forwarded to the patient’s attending physician. Agency policy Discharge from Hospice Program, required in part, “A copy of the discharge summary will be sent to the attending physician. If requested, the patient’s clinical record will be provided.” Clinical Record 18: The patient elected hospice benefit on 12/23/2023 and signed the revocation of hospice services on 07/30/2024. Clinical record review revealed no documented evidence that a discharge summary was developed and sent to the patient’s attending physician. During an interview on 12/12/2024, the Director of Patient Care Services stated they are planning on educating the clinical and administrative staff on the discharge process.”

“Observed in Record Review. In 5 of 6 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#2 there was documentation of a fall and difficulty swallowing with changes in diet, yet the changes were not reflected in the plan of care. In RRNHV#2, RRNHV#3, RRNHV#4, and RRNHV#5 the psychosocial and spiritual services were ordered yet there were no psychosocial or spiritual care plans established. In RRNHV#6 there was documentation of changes in mobility, fall risk, and diminishing motor skill yet the issues were not reflected in the care plans. Further the chaplain documented visits but no spiritual care plan. These observations were reviewed with the DPCS.”

“Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. On review of RRNHV#1 goals were noted to not be SMART such as Minimize complications due to impaired mobility and Pt/pcg will verbalize understanding of medication/treatment orders and side effects All of the goals had an achieve by date of the end of the certification period. In RRNHV#2 examples were Pt needs will be met daily as communicated. -Will minimize episodes of confusion and forgetfulness. -Pt/pcg will verbalize understanding of medication/treatment orders and side effects. In RRNHV#3 example was Pt needs will be met on a day to day basis as communicated. Goals that lacked being specific, measurable, and time-bound were noted throughout all records reviewed. These observations were reviewed with the DPCS.”

“Observed in Record Review. In 3 of 3 patient records reviewed, The organization failed to maintain complete and accurate records, as the surveyor noted the pt records were inaccurate or contains errors. RR#1, #2 and #3 contained different numbers of PRN visits for the SN visits and PRN visits without reasons the visits should be performed. The POC Summary was different from the Frequency of Visits on the IDG summary in the records reviewed. In addition during RR#1, the RN initial assessment listed comorbidities of COPD, pneumonia and HTN that were not listed on the POC. RR#2, RN initial assessment listed GERD, constipation, asthma, seizures and pressure ulcers that were not listed on the POC. RR#3 RN initial assessment included diabetes, insulin dependent that was not listed on the POC. This was discussed with the DPCS and DPCS designee.”

“Observed in Record Review. In 3 of 3 patient records reviewed, Goals on the POCs lack measurable outcomes. RR#1 goals: ADL needs are met to an optimal level. Maintain optimal value of blood pressure. Prevent discomfort related to edema in bilateral lower extremities. Facilitate bowel elimination and comfort. Minimize risk of fall. Patient will tolerate performing activities of daily living (ADLs). The patient will free from complications related to weakness. Pt needs will be met on a day-to-day basis as communicated. Pt will remain free of injury. Pt will have adequate food and fluids as tolerated or desired. Pt will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication. Patient, family and PCG will verbalize comfort in taking care of their loved ones needs. Patient, family and PCG will verbalize that there will be sufficient care at home setting till the end of life. Minimal episodes of shortness of breath. Promote comfort level. RR#2 goals: Pt will maintain optimum peripheral circulation. The patient/ pcg will verbalize understanding of the disease process and potential complications. Facilitate bowel elimination and comfort. Altered skin will heal for patient comfort. Altered skin will be free of infection. Minimize complications related to impaired mobility. Patient will tolerate performing activities of daily living (ADLs). Pt needs will be met on a day-to-day basis as communicated. Pt will remain free of injury related to seizures. Minimal episodes of shortness of breath. Promote comfort level. RR#3 Patient will maintain BP within individually acceptable range. Patient will demonstrate stable cardiac rhythm and rate within patient’s normal range. Patient will participate in activities that will prevent stress (stress management, balanced activities and rest plan). Blood sugar management for pt. comfort. Prevent hospitalization. Patient will not sustain a fall or injury due to fall to be assessed every SN visit. Prevent pain and discomfort due to injury. Pt/Family/PCG will verbalize understanding of increased risk of fall. Improve bowel function and relieving associated symptoms such as bloating and pain. Reduce discomfort with improved bowel elimination status. Patient demonstrates the use of adaptive devices to increase mobility Patient uses safety measures to minimize potential for injury. Medicate before procedures and activities. Patient/ pcg will identify the factors that aggravate decreased tolerance to activity. Patients will have behavioral problems identified and controlled. Pt will remain free of injury. Pt will have adequate food and fluids as tolerated or desired. Pt/Family/PCG will verbalize understanding that symptom is a part of the disease process and the limitations of treatments. The findings was discussed with the DPCS.

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“Observed in Record Review. In 3 of 3 patient records reviewed, During RR#1, 2 and #3 it was noted the frequency of visits for SN, and MSW lacked either the number of PRN visits ordered or the reason for the PRN visits to be completed. RR#1: MSW: Initial Assessment and once month as needed, RN: 1 per 2 Week + 1 PRN Visits, SC: 1 - Initial Assessment and once month as needed, SN: 1 per Week +3 PRN Visits. The frequencies were correct on the POC summary but incorrect on the IDG summary. RR#2: RN to perform LVN supervisory visits every 30 days and as needed for any change of patient’s condition. RN to perform reassessment every 14-15 days and as needed for any change of patient’s condition. SN visit once per week for clinical care and support and as needed for any change of patient’s condition. RR#3 MSW: 1 As needed and Recert - Initial Assessment and Recertification, RN: 1 per 2 Week + 1 PRN Visits, SC: 1 As needed and Recert - Initial Assessment and Recertification, SN: 1 per Week +3 PRN Visits on POC summary: RN to perform LVN supervisory visits every 30 days and as needed for any change of patient’s condition. RN to perform reassessment every 14 days and as needed for any change of patient’s condition. SN visit once a week for clinical care and support and as needed for any change of patient’s condition. The findings were discussed with the DPCS an DPCS designee.



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“Observed in Record Review. In 5 of 6 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#2 there was documentation of a fall with wounds yet the changes were not reflected in the plan of care. In RRNHV#3 the documentation noted the patient was treated for a UTI yet there was no care plan to direct the care. In RRNHV#4 the only care plan open was for pain, yet the patient had a terminal diagnosis of COPD and multiple wound but no care plans to guide the care. Further, there were no physicians orders noted for oxygen even though the supply list noted oxygen in the home, nor were there wound care orders but the patient had documentation of multiple wounds and treatments provided. In RRNHV#5 there was documentation of an infection to the patient’s toes treated with antibiotics but the issue was not reflected on the care plan. In RRNHV#6 the chaplain documented visits but no spiritual care plan. These observations were reviewed with the Office Manager and DPCS.”

“Observed in Record Review. In 6 of 6 patient records reviewed, the Surveyor noted members of the Interdisciplinary Group had not completed their initial assessments within five days after the election of hospice. In review of all 6 active records reviewed, it was noted that all failed to complete the comprehensive assessment within 5 calendar days of the election of hospice. On RRNHV#1, RRNHV#2, and RRNHV#3 there was no documentation of an initial spiritual assessment. In RRNHV#3 and RRNHV#4 there was no documentation of a psychosocial assessment completed. In RRNHV#5 there comprehensive assessment was not completed withing 5 days as the MSW completed on day 10 and the SC completed on day 13. In RRNHV#6 the MSW completed the psychosocial assessment on day 25 and the spiritual counselor on day 18. These observations were reviewed with the Office Manager and DPCS.”

“Observed in Record Review. In 4 of 6 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRNHV#1, and RRNHV#2 there was no documentation of a spiritual assessment completed on the record. Documentation on the RN initial comprehensive assessment noted that a spiritual assessment was needed. In RRNHV#3 there was no documentation of a psychosocial or spiritual assessment completed. There was documentation noted of calls to schedule a visit but no documentation of any attempt beyond calls to complete the assessment, nor discussion with the IDG team of efforts to complete. In RRNHV#4 there was no documentation of a psychosocial assessment completed. These observations were reviewed with the Office Manager and DPCS.”

“Observed in Record Review. In 2 of 6 patient records reviewed, The organization failed to ensure the comprehensive assessment was accomplished by the hospice interdisciplinary group no less frequently that every 15 days. For example: on review of RRNHV#2 the last documented comprehensive assessment was noted in mid October leaving a 28 day gap in update to the comprehensive assessment. An RN visit was documented early November yet was documented as a limited (short form) visit and did not document a comprehensive assessment. In RRNHV#4 there was documentation of RN visits completed yet each visit for October (total of 3) were blank with only a time in and time out without documentation of a comprehensive assessment as required. These observations were reviewed with the Office Manager, and DPCS.”

“Observed in Record Review. In 3 of 6 patient records reviewed, The organization failed to maintain complete and accurate records, as the surveyor noted the pt record was inaccurate or contains errors (i.e. conflicts with other documentation). For example: on review of RRNHV#2 the IDG documentation from the RN noted the patient skin intact and then goes on to say the patient with 2 wounds to the right arm. Further, there was a conflict in the frequency for the MSW and Chaplain as the IDG documentation noted 1 time a week, yet the physician order noted both the MSW and Chaplain at as needed only. In RRNHV#3 the physicians order for SN was noted to be 1 x week, yet the IDG documentation noted 2 x week. The documentation noted the SN was visiting 1 x week. In RRNHV#4 the Physicians order for SN said 2 x week, yet the IDG documentation noted 1 x week. These observations were reviewed with the DPCS.”

“Observed in Record Review. In 5 of 6 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. On review of RRNHV#2 goals were noted to not be SMART such as Patient will be aware and oriented if possible, and reality will be maintain at an optimal level. Patient will have improved thought processing or will be maintained at a baseline level, and Medicate before procedures and activities. The goals all had a target date for the end of the year. In RRNHV#3 examples were Patient will participate in activities that reduce BP/cardiac workload. Patient will maintain BP within individually acceptable range. Patient will demonstrate stable cardiac rhythm and rate within patient’s normal range. In review or RRNHV#4 the only goal was noted for pain with no further goals were established. In RRNHV#5 non-specific without target dates examples were The patient/ pcg will identify the relationship of signs/symptoms to the disease process and correlate symptoms with causative factors. The patient/ pcg will verbalize understanding of therapeutic needs. In RRNHV#6 examples were Patient will have improved thought processing or will be maintained at a baseline level and patients will have behavioral problems identified and controlled. These observations were reviewed with the Office Manager and DPCS.”

“Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to ensure the patient care and services were provided in accordance with the plan of care. For example: on review on RRNHV#2 the aide was ordered a frequency of 2 times a week, but in week 3 only one visit was made, no visits were documented in week 4, and only one visit documented in week 5 of the current benefit period. Further, the SN was ordered 2 x week but no SN visits were documented for week 2, and only one SN visit was noted in weeks 1 and 4. In RRNHV#4 there were no documented SN visits the last week of September. In RRNHV#5 the SN was ordered 1xwk yet there were no SN visits documented in weeks 2, 4, 6, and 8 of the current benefit period. These observations were reviewed with the Office Manager and DPCS.”

“Observed in Record Review. In 2 of 5 patient records reviewed, where the patient had Hospice Aide (HA) care, the Surveyor noted HA supervision not completed every 14 days. In review of RRNHV#2 the documentation noted there to be a 28 day gap since last aide supervisory visit completed in the record. In review of RRNHV#4 there were RN visits noted in the record for every other week in October yet the entries noted a time in and time out only and did not document aide supervisory visits completed for the month of October and to date of survey. These observations was reviewed with the Office Manager and DPCS.”